Download Standards for Thoracic Surgical Oncology in a Single

REVIEWS
Standards for Thoracic Surgical Oncology in a
Single-Payer Healthcare System
Sudhir Sundaresan, MD, Bernard Langer, MD, Tom Oliver, BA, Farrah Schwartz, MA,
Melissa Brouwers, PhD, Hartley Stern, MD, and the Expert Panel on Thoracic Surgical
Oncology*
The Ottawa Hospital, Ottawa; Cancer Care Ontario, Toronto; Program in Evidence-Based Care, McMaster University, Hamilton;
and Ottawa Regional Cancer Centre, Ottawa, Ontario, Canada
Through systematic literature review and a consensusbased approach from an expert panel, standards on the
organization for delivering thoracic cancer surgery in a
single-payer healthcare environment were developed.
Thirty-two studies and six organizational reports were
identified. Results from 32 studies showed a trend toward higher volumes and improved patient outcomes,
and six consensus reports provided recommendations on
thoracic care standards. Thoracic surgical oncology standards in a single-payer healthcare system were developed. The benefits associated with the implementation of
thoracic cancer surgery standards should result in increased regionalization of care, improved processes of
care, and better patient outcomes.
(Ann Thorac Surg 2007;84:693–701)
© 2007 by The Society of Thoracic Surgeons
O
Patients
The patients are described as those who have cancer and
who require thoracic surgical oncology services for lung
or esophageal carcinoma in a single-payer healthcare
system.
Methods
Evidence Search and Literature Search Strategy
The literature was systematically searched for published reports addressing the optimum delivery of
thoracic surgical care for patients with lung or esophageal carcinoma. Published sources included the medical databases MEDLINE (OVID, 1990 through December 2004), EMBASE (OVID, 1990 through December
2004), the Cochrane Library (OVID, Issue 4, 2004), the
Canadian Medical Association Infobase, and the National Guideline Clearinghouse, as well as abstracts
published in the proceedings of the meetings of the
American Society of Clinical Oncology (1997–2004) and
the American Society for Therapeutic Radiology and
Oncology (1992–2003). Article bibliographies and personal files were also searched for evidence relevant to
this report.
Unpublished sources were sought by contacting the
Ontario heads of surgical oncology in each region, conducting a web search of Canadian provincial and national
thoracic surgery associations, American and European
thoracic organizations, and through direct contact with
leaders in the field.
*See Appendix for the members of the Expert Panel on Thoracic Surgical
Oncology.
Study Selection Criteria
Address correspondence to Dr Sundaresan, c/o Tom Oliver, McMaster
University, 1280 Main St W, DTC, 3rd Floor, Hamilton, Ontario, L8S 4L8,
Canada; e-mail: [email protected].
Reports were selected for inclusion in this systematic
review of the evidence if they reported information on
organizational resources relating to improved outcomes
© 2007 by The Society of Thoracic Surgeons
Published by Elsevier Inc
0003-4975/07/$32.00
doi:10.1016/j.athoracsur.2007.03.069
REVIEWS
ntario is the most populous province in Canada
with a population of approximately 12 million
people spread over more than 1 million square kilometers [1]. In Ontario, thoracic surgical oncology services
are provided within a single-payer tax-based healthcare
system in many university and community hospitals,
both large and small. A comprehensive approach to the
diagnosis and staging of patients is essential to establish
correct diagnosis, to select those patients with apparently
localized disease as candidates for potentially curative
resection, and to correctly understand the prognosis. This
is in addition to determining the need for additional
(adjuvant) therapies, enrolling patients in clinical trials,
and reaching any meaningful conclusions about the
outcome of thoracic cancer care. Also, increasing evidence indicates that there is a survival benefit afforded by
preoperative or postoperative adjuvant therapy for many
surgically resected lung cancers [2]. Thus, there is a
strong case associated with survival benefit for the patient to approaching these cancers from a multidisciplinary perspective with collaborative input and leadership from different specialists.
There is a need for quality standards for thoracic
cancer surgery to improve patient outcomes, especially
with the increased volumes of thoracic surgery anticipated in the coming years due to a growing and aging
population. The optimum method of organizing the delivery of thoracic surgical oncology care has not been
well-established in the medical or organizational
literature.
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Ann Thorac Surg
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Table 1. Reports of Differences in Surgical Practice Affecting Patient Outcomes
Author, Year,
Reference No.
Resection Type
High versus low surgical volume
Treasure, 2005 [3]
Lobectomy
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High volume
Low volume
High volume
Low volume
High volume
Low volume
High volume
Low volume
High volume
Low volume
High volume
Low volume
High volume
Low volume
⬎ 47
⬍ 15
⬎ 17
⬍7
⬎6
⬍2
⬎ 31
⬍ 22
NR
NR
⬎ 20
⬍2
ⱖ6
ⱕ5
2.5%
2.7%
5.0%a
6.1%
9.2%a
18.8%
0.9%
2.6%
Lowera
Higher
10.2%
ⱖ 15.0%
0.0%a
22.0%
High volume
High volume
High volume
High volume
Low volume
NR
NR
NR
NR
⬎ 20
⬎ 20
⬎ 20
⬃ 58
⬃ 22
NR
NR
NR
NR
5.1%
5.2%
6.1%
5.5%
7.7%
3.0%a
5.3%
11.8%
20.2%
⬍ Experience
⬎ Experience
⬃ 23
Specialty
Thoracic
Cardiothoracic
Birkmeyer 2003 [4]
Lung
NR
NR
Esophagectomy
NR
NR
Hannan, 2002 [5]
Lobectomy
NR
NR
Bachman, 2002 [6]
Esophageal
NR
NR
Gillison, 2002 [7]
Cardioesophageal NR
NR
Miller, 1997 [8]
Esophagectomy
NR
NR
Thoracic specialist compared with other surgeons
Goodnev, 2005 [9]
Lung
Thoracic
Cardiothoracic
General
Martin-Ucar, 2004 [10] Lung
Thoracic
Cardiothoracic
Silvestri, 1998 [11]
Lobectomy
Thoracic
General
Pneumonectomy
Thoracic
General
Learning curve for esophageal survey
Sutton, 1998 [12]
Esophagectomy
NR
a
Comparison
Volume
per
Year
30-Day
Mortality
(%)
NR
NR
Length
of Stay
(days)
Morbidity
Overall
Survival
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
Longera
Shorter
15%
15%
NR
NR
NR
NR
NR
NR
NR
11.8
11.6
11.5
14.9
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
31%
32%
NR
NR
NR
NR
Highera
Lower
NR
NR
NR
NR
Indicates statistically significant differences at p ⬍ 0.05; all other comparisons were either not statistically compared or were not reported.
NR ⫽ not reported.
for patients undergoing cancer-related thoracic surgery.
Patient-related outcomes of interest include tumor response, local disease control, survival, adverse events, or
quality of life.
Practice guidelines, meta-analyses, or systematic reviews related to the research question were also eligible
for inclusion in the systematic review of the evidence.
Articles were excluded from the systematic review of
the evidence if they reported information on thoracic
surgeries for tumors in locations other than the lung or
esophagus, if they were published or developed prior to
1990, or if they were in a language other than English, or
a combination of these.
Results
A total of thirty-two studies [3–34] and six organizational
reports were identified [35– 40]. Results relating to surgical, hospital, or organizational characteristics affecting
patient outcomes are presented in Tables 1, 2, and 3.
Characteristics Report
Overall, the quality of the evidence identified was modest. No randomized controlled trials were identified in
the search of the literature, and reports based on discharge data from hospital, regional, or national databases
were primarily retrospective. One challenge to interpreting and applying the evidence findings is that the reported outcomes are confounded by interdependent factors that can affect causality. Factors such as differences
in referral practices, patient characteristics, disease characteristics, surgical complexity, surgical or hospital volume, presence or absence of a multidisciplinary team can
all interact to influence outcomes. Where available, data
that are adjusted for potentially confounding factors are
reported.
Thirty-day mortality or in-hospital mortality was commonly reported. However, reporting of other outcomes
such as length of stay, morbidity, or overall survival was
inconsistent and incomplete. Most of the reports investigated whether surgical or hospital volume affected pa-
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Table 2. Reports of Differences in Hospital Volume or Type Affecting Patient Outcomes
Resection
Type
No. of
Hospitals
High versus low hospital volume
Hannan, 2002 [5]
Lobectomy
Bachman, 2002 [6]
Urbach, 2004 [13]
Finlayson, 2003 [14]
15
134
Esophageal
resection
Esophagectomy
NR
NR
47 Total
Lung resection
47 Total
Esophagectomy
40
603
37
512
37
512
Lobectomy
Pneumonectomy
Finlayson, 2003 [15]
Lung resection
Christian, 2003 [16]
Esophagectomy
Dimick, 2003 [17]
Esophagectomy
Dimick, 2003 [18]
Esophageal
resection
Esophageal
resection
Esophagectomy
NR
NR
NR
NR
NR
NR
van Meerbeeck, 2002
[21]
Birkmeyer, 2001 [22]
Lung resection
Kuo, 2001 [23]
Esophagectomy
van Lanschot, 2001
[24]
Dimick, 2001 [25]
Esophagectomy
Bach, 2001 [26]
Lung resection
Swisher, 2000 [27]
Esophagectomy
6
138
204
162
31
618
79
1806
79
944
NR
NR
NR
NR
3
61
757
928
3
39
2
34
101 Total
Khuri, 1999 [28]
Lung resection
107 Total
Begg, 1998 [29]
Esophagectomy
NR
NR
NR
NR
Dimick, 2003 [19]
Birkmeyer, 2003 [20]
Lobectomy
Pneumonectomy
Esophagectomy
Esophagectomy
Pneumonectomy
Patti, 1998 [30]
Esophagectomy
Romano, 1992 [31]
Lung resection
a
5
196
NR
NR
Volume
30-Day
Mortality
(%)
Length
of Stay
⬎ 168
⬍ 38
High
Low
⬎ 8.8
⬍ 8.8
⬎ 8.8
⬍ 8.8
⬎ 9.0
⬍ 4.0
⬎ 37
⬍ 19
⬎ 37
⬍ 19
⬎ 41
⬍8
ⱖ 10
⬍3
⬎6
ⱕ6
⬎ 16
⬍3
⬎ 8.5
⬍ 8.5
⬎ 19
⬍2
⬎ 19
⬍2
⬎ 19
⬍2
ⱖ 35
⬍5
High
Low
28
1.1
⬎ 20
ⱕ 10
⬎ 15
ⱕ3
⬎ 66
⬍9
ⱖ5
⬍5
14–44
ⱕ5
ⱖ 11
ⱕ5
ⱖ 11
ⱕ5
⬎ 30
ⱕ5
⬎ 24
⬍9
0.9%a
3.1%
Lower
Higher
10.9%
15.6%
3.5%a
4.9%
6.5%a
15.0%
3.5
4.3
8.9
10.6
ⱕ 4.9%
ⱖ 6.9%
Lowera
Higher
NR
NR
3.7%a
11.8%
2.5%a
15.4%
8.1%a
23.1%
4.2%a
6.4%
10.6%a
17.0%
3.5%
6.9%
5.9%a
15.8%
2.5%a
9.2%
4.9%a
12.1%
2.7%a
16.0%
3.0%a
6.0%
3.0%a
12.2%
5.2%
7.1%
3.4%a
17.3%
10.7%
13.8%
6%
17%
9.2%
14.2%
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
⬎ 20 days ⫽ 20%a
⬎ 20 days ⫽ 28%
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
13 daysa
15 days
NR
NR
11 daysa
19 days
NR
NR
14.7 daysa
17.7 days
NR
NR
NR
NR
NR
NR
22 days
22 days
NR
NR
Morbidity
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
39%a
48%
NR
NR
⬍ In HV hospitals
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
Indicates statistically significant differences at p ⬍ 0.05; all other comparisons were either not statistically compared or were not reported.
NR ⫽ not reported.
Overall
Survival
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
6.6
5.4
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
33%**
44%
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
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Author, Year,
Reference No.
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2007;84:693–701
Table 3. Reports of Hospital Type Affecting Patient Outcomes
Author, Year,
Reference No.
Organization
Hospital type affecting patient outcomes
Mine, 2000 [32]
Specialist centre
District hospital
Dimick, 2004 [33]
Teaching hospital
Nonteaching
Tanaka, 1994 [34]
Teaching
Large 400⫹ beds
Med. 150–399 beds
Small ⬍150 beds
a
Volume
NR
NR
Mixed
Mixed
NR
NR
NR
NR
Resection
Type
No. of
Patients
Esophageal
53
60
NR
NR
NR
NR
NR
NR
Esophageal
Lung
30-day
Mortality
(%)
% With
Prolonged
Length of
Stay
5.6%
12.5%
7.7%
10.2%
Lowera
Higher
Higher
Higher
NR
NR
26.5%
23.1%
NR
NR
NR
NR
Morbidity
Overall
Survival
(Years)
NR
NR
NR
NR
NR
NR
NR
NR
63%
62% (1 year)
NR
NR
NR
NR
NR
NR
Indicates statistically significant differences at p ⬍ 0.05; all other comparisons were either not statistically compared or were not reported.
NR ⫽ not reported.
REVIEWS
tient outcomes, but there were no common criteria across
reports as to what constituted high volume or low volume, and the data on volumes were reported in a
variable manner. In light of the variation in volume
categorization, a volume cut-off was not established for
this data set. Where multiple volumes were reported
within a given study, reviewers extracted data that compared the highest volume data with the lowest volume
data. Where the data were categorized in a dichotomous
manner by the studies, those values were added to the
data tables as reported. Although not ideal, those decisions were made with the underlying rationale that
extreme volume differences would better inform the
outcomes of interest, and in the case of dichotomous
volume outcomes, a volume cut-off would result in undue amounts of missing data.
lower for patients treated by a thoracic surgeon compared with a general surgeon, but that difference was not
statistically significant. One study [10] reported no significant differences in patient outcomes with the introduction of a thoracic surgeon compared historically with
cardiothoracic surgeons; however an increase in surgical
volume, complex procedures, and operations on elderly
patients was reported.
One article investigating the role of an individual
surgeon’s experience over time in relation to patient
outcomes reported that as the level of experience increased, improvements in the patient’s outcomes were
observed. Significant reductions in single-lung operating
time, blood loss, transfusion requirements, hospital stay,
and an increased yield of lymph nodes was noted [12].
Twenty-one reports with 27 evaluations
[5, 6, 13–31] compared differences in patient outcomes by
hospital volume (Table 2), and three reports [32–34]
compared differences in hospital type that were identified in the systematic review of the literature (Table 3).
As seen in Table 2, the range in volume comparison
across the 21 reports is quite large for both lung and
esophageal resections. In every instance, however, 30day mortality was reported to be lower in higher volume
centers when compared with lower volume centers. The
difference in 30-day mortality was reported to be statistically significant in 16 of 27 comparisons [5, 13, 14, 16,
18 –20, 22–27, 29].
Length of stay was reported in 5 of 21 studies. In four
of five studies, length of stay was significantly shorter for
patients treated at high-volume centers. Two studies
reported lower morbidity in the higher-volume centers
[16, 19], and one study reported a significant difference in
overall survival for patients treated in a high-volume
center [26].
As seen in Table 3, although the numbers were small,
a retrospective comparison of an esophageal surgery
center with a district hospital performing similar operations [32] reported no significant differences in 30-day
mortality or in 1-year overall survival. In two studies,
HOSPITAL CRITERIA.
Ten reports comparing patient outcomes by surgeon volume [3– 8], surgeon specialty [9 –11],
or individual surgical experience [12] were identified in
the systematic review of the literature and are presented
in Table 1.
Although the cut-offs for high versus low volume were
arbitrarily chosen, of the six reports that compared patient outcomes by high-surgeon volume versus lowsurgeon volume, three reports had significantly lower
30-day mortality for those patients who were treated by
surgeons with higher yearly volume than those with
lower surgical volumes [4, 6, 8]. Thirty-day mortality
ranged from 0% to 22% in those studies. One study also
reported a significant overall survival advantage for patients treated by high-volume surgeons as compared
with low-volume surgeons [6]. The remaining three studies did not report any significant differences between
volume groups [3, 5, 7].
Of the three studies comparing thoracic surgeons to
cardiothoracic or general surgeons, one study reported
significantly less 30-day mortality for patients undergoing lobectomy when treated by a thoracic surgeon as
compared with a general surgeon [11]. For patients undergoing pneumonectomy, the mortality rate was 8%
SURGEON CRITERIA.
outcomes from teaching hospitals were retrospectively
compared with nonteaching hospitals [33, 34]. One of
these [33] reported no significant differences between
groups in an unadjusted analysis of 30-day mortality or
length of stay. After adjusting for hospital volume, the
risk of a prolonged length of stay was significantly higher
in the nonteaching hospitals than in the teaching hospitals (odds ratio ⫽ 0.5; 95% confidence interval, 0.3– 0.8). In
the other study [34], patients treated in teaching hospitals
had significantly lower risks of death than those treated
in small, medium, or large nonteaching hospitals; however, specific rates were not reported.
There were no studies identified
in the search of the literature that compared organizational criteria as they relate to improved patient outcomes after lung or esophageal resection.
ORGANIZATIONAL CRITERIA.
Environmental Scan Results
Six practice organization documents [35– 40] were located
through consultation and web search of published and
unpublished literature. All of the practice organization
documents were developed through expert consensus
[35– 40]. The documents were generally consistent in
their results. Most documents highlighted the importance of multidisciplinary collaboration as being vital to
best patient care, including regular multidisciplinary
rounds and established clinical leadership. Listed members of the multidisciplinary teams included representatives from thoracic surgery, respirology, anesthesia, medical oncology, radiation oncology, radiology, pathology,
dedicated nursing, and palliative care. Most of the documents also discussed appropriate staffing levels for
thoracic units. The two Canadian documents [35, 39]
recognized the need for thoracic units to have affiliations
with cancer centers as well as sufficient on-call coverage
provided by thoracic surgeons.
The documents also discussed the requirements for
thoracic surgeons and agreed on the need for specialist
training in thoracic surgery. The need for continuing
medical education was also recognized as an important
requirement for surgeons.
Resources discussed in the practice organization documents included fully equipped operating rooms with
protected operating room time, a dedicated thoracic ward
and intensive care unit beds, specified volumes and
diagnostic facilities, as well as appropriate institutional
affiliations, organization of care, and quality monitoring.
Human resource measurements included surgical caseload, multidisciplinary team members, and standards for
number of resections per thoracic surgery unit per year.
Comment
Overall, the quality, quantity, and generalizability of the
body of evidence on the optimum organization for the
delivery of cancer-related thoracic surgery identified in
the literature are limited. Studies of volume and outcome
relationships as indicators of patient outcome contain an
inherent risk of bias and potentially confounding co-
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interactions. There was also uneven reporting of outcomes across trials, and little consensus in the data as to
what constitutes high or low volume. Notwithstanding
these limitations, the results of the studies were consistent. Whether statistically significant or not, outcomes for
patients were typically more favorable if they were
treated by surgeons with higher volumes, surgeons with
more experience, or by specialists in thoracic surgery. In
terms of hospital criteria that might influence patient
outcomes, treatment in higher volume hospitals and in
specialist and teaching hospitals rather than general
hospitals was generally associated with better patient
outcomes. In none of these studies was there evidence of
specific structural or process factors that might have been
responsible for the volume-outcome relationship.
The literature search identified no studies that compared organizational criteria as they relate to improved
patient outcomes after lung or esophageal resection.
The six practice organization documents identified
in the search were also generally consistent in most
aspects. The consensus panels or working groups generally recommended specialist training in thoracic surgery,
practice in multidisciplinary treatment groups, protected
operating room times, sufficient resources to perform the
latest techniques with appropriate staffing, diagnostics,
and postoperative care.
Through a systematic review of the published and grey
literature, and expert consensus opinion, thoracic cancer
surgical standards were developed by an expert panel of
thoracic surgeons, other medical specialists, hospital administrators, and planners. To facilitate document development, a smaller writing group (consisting of three
senior surgeons and two research coordinators providing
methodological support) was formed. The writing group
met through teleconferences and in-person meetings and
used e-mail as the main vehicle of communication. The
full expert panel met on three occasions to discuss the
draft produced by the writing group, come to a consensus, and give approval of the final draft. Over 100
practitioners and administrators across Ontario were also
given the opportunity to provide comments and critique.
Differences were resolved through consensus and the use
of evidence for the standards document.
Standards for Thoracic Surgical Oncology in a
Single-Payer Healthcare System
Please note that while the process of standards development was rigorous, according to grading conventions the
evidence available to form the standards is of very low
quality [41]. The standards presented below represent
strong recommendations for practice. They are based on
expert consensus opinion with primary consideration
given to the perceived benefits for patients and the small
likelihood of any harm arising from implementation of
the standards.
Surgeon Criteria
Characteristics for surgeons undertaking the management of patients with thoracic cancer include:
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● Knowledgeable about thoracic cancer biology, behavior, and natural history.
● Well informed about appropriate investigation techniques, multidisciplinary treatment options, as well as
postoperative management and the continuum of care.
● Skilled in modern techniques of surgery of the thoracic
region.
● Experienced in the management of patients with thoracic diseases, specifically with the management of
their complications, early and late.
● Committed to providing excellence in care to patients
with thoracic diseases, specifically cancer patients, and
to advancing knowledge in the field to improve patient
outcomes.
● Committed to participating as a member of a multidisciplinary oncology team or to consult with such teams.
● Committed to participating in Cancer Care Ontario
initiatives, particularly those of the Surgical Oncology
Program or in the Program in Evidence-Based Care, or
both, through membership in working groups, standing groups, or as active participants in external review
and consultation processes.
Training
REVIEWS
● Surgeons should have formal training in programs
such as the Royal College of Physicians and Surgeons
of Canada programs in thoracic surgery, cardiothoracic surgery, or cardiovascular and thoracic surgery,
or the American Board of Thoracic Surgery or other
equivalent training recognized in Canada, and be
certified and licensed to practice thoracic surgery in
Canada.
● Surgeons should maintain expertise and competence
through ongoing education in available Continuing
Professional Development programs, such as the
Maintenance of Certification program of the Royal
College of Physicians and Surgeons of Canada or
others.
Practice Setting
● Level 1 tertiary care regional thoracic centers should
be equipped to manage the full range of thoracic
surgical care, as well as acting as the primary source to
manage the most complex cases. To facilitate this goal,
there should ideally be at least three thoracic surgeons
on staff to provide intraoperative assistance and postoperative care, and weekend, holiday, and emergency
coverage.
X This number of surgeons is needed to provide the
capacity for tertiary clinical care in addition to the
other requirements and responsibilities of a multidisciplinary cancer care facility, including teaching, research, quality improvement, and program
advancement.
X A team approach is understood to improve the
quality of surgery in complex cases and the judgment required to manage complications.
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● In some regions, the population may not support a
level 1 thoracic center. In these regions, a level 2, or
secondary care unit, may be established to serve the
basic thoracic surgery needs of the population.
X Level 2 centers should have:
X A minimum of one thoracic surgeon who performs routine thoracic procedures.
X A formalized relationship with a level 1 tertiary
center to which the thoracic surgeon may refer
complex thoracic cases (eg, tracheal resections,
major chest wall resections, and so forth).
X Arrangements with surgical colleagues in those
centers to provide support in the event of the
thoracic surgeon’s absence.
● Hospitals not meeting level 1 or 2 thoracic surgery
criteria should establish formal relationships with a
level 1 or level 2 center to facilitate consultation and
appropriate management and referral of patients with
thoracic malignancies. For those hospitals where the
geographic location, patient volume, or population
catchments do not support level 1 or 2 status, the basic
thoracic service needs may still be provided in that
area through formal relationships with level 1 and 2
centers. Guided by the expertise of these centers,
much of the initial and preoperative evaluation can be
conducted at that hospital itself. The surgical care
would require transferring the patient to the level 1 or
2 thoracic surgery unit. However, upon completion of
the surgery, the patients can return to the originating
center for ongoing care and follow-up as deemed
appropriate and necessary by the multidisciplinary
group at the level 1 or 2 center.
Volume of Thoracic Surgery
The standards of surgical volumes are not based on
high-quality evidence, but rather on the consensus of an
expert panel. Although a volume-outcome relationship
was observed in the literature, the standards of volumes
were primarily based on the established need for sufficient volumes to sustain dedicated services (eg, respirology, intensive care unit, physiotherapy, pathology, diagnostic imaging, and so forth), and a sufficient volume to
support adequate coverage for full service units. These
volumes were considered reasonable by the expert panel
in light of the current distribution of thoracic surgery in
the province, but it is recommended that these numbers
be revisited as more data becomes available.
● The practice setting should have a sufficient volume of
thoracic surgery to maintain the skills of surgeons in
both complex cancer surgery and thoracic surgery.
● Surgical volumes in the range of 20 esophagectomy
cases per unit per year and 150 anatomic pulmonary
resections per unit per year should be considered
targets for level 1 centers.
● Surgical volumes in the range of seven esophagectomy
cases per unit per year and 50 anatomic pulmonary
resections per unit per year should be considered
targets for level 2 centers.
● The panel recognized that some regions may not
have the population and cases to support the recommended target volumes, but could meet them as the
predicted increase in cancer cases occurs.
Hospital Criteria
Important characteristics of the institution in which major thoracic cancer surgery would take place are:
● Commitment to high-quality, multidisciplinary thoracic cancer care.
● Commitment to providing or participating in an organizational structure to manage patients with these
cancers through all phases of their care.
● Commitment to participate in activities that advance
Cancer Care Ontario Provincial Cancer Plan (2004).
● Formal working relationship or association with a
regional cancer center if a thoracic surgery unit is not
located at the cancer center.
Physical Resources and Collaborating Services
The following physical resources and collaborating services are considered to be reasonable criteria that level 1
and 2 hospitals providing thoracic cancer surgery should
be expected to meet in providing comprehensive acute
care:
● Operating room available 24 hours per day, 7 days per
week (24/7), with video capacity for bronchial and
esophageal scopes, video-assisted thoracic surgery
and laparoscopy, intraoperative fluoroscopy capacity,
and frozen section available 24/7 for emergencies.
● An interventional radiology suite that has the capacity
for needle biopsy of lung and chest masses and drainage of loculated pleural collections that is available
24/7 for emergencies, either onsite or at an on-call
hospital. The capacity for embolization therapy for
massive hemoptysis or prior to massive chest wall
resections is essential for level 1 centers.
● Full spectrum of radiologic imaging, including roentgenogram and immediate portable roentgenogram access 24/7 for emergencies, esophageal contrast studies,
computed tomography, magnetic resonance imaging,
ultrasound, nuclear medicine, and vascular imaging.
● For level 1 units, a dedicated thoracic surgical service
with consolidated beds to ensure an appropriate level
of nursing, physiotherapy, and respiratory therapy
expertise.
● Specialized nursing care, including mechanical ventilation and invasive monitoring in a combination of
intensive care unit and step-down beds sufficient to
support the volume of patients treated.
● Affiliation with a regional cancer center with access to
radiation therapy equipment and consultation from
medical and radiation oncologists.
● Ambulatory endoscopy facility with access to surgeons, pulmonologists, and gastroenterologists.
● Onsite laboratory for pulmonary function tests and
cardiac diagnostic assessment services, including
echocardiography and nuclear imaging.
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● Onsite rapid response laboratory (ie, biochemistry,
hematology, transfusion, and microbiology) services
sufficient to support operating room, intensive care
unit, step-down, and ward requirements 24/7.
● Onsite or rapid access to pathology and cytology
services sufficient to support operating room, endoscopy, and ambulatory services.
Human Resources
The human resources should include:
● Thoracic surgeons.
● Anesthesiologists skilled in thoracic anesthesia
techniques.
● Other medical specialists including gastroenterologists, pulmonary medicine specialists, intensivists, a
thoracic pathologist, and a radiologist with a subspecialty interest in diagnostic and interventional procedures of the chest.
● Allied professionals, including dedicated nurses; chest
physiotherapists accessible 7 days a week; respiratory
therapists available 24/7; dietary and nutritional, home
care, social work, and pharmacy support; and access to
a palliative care team.
● Formalized partnerships and access to oncology specialists including medical oncologists and radiation
oncologists.
● Access to other consulting specialties as needed,
such as infectious disease, cardiology, and neurology specialists.
Organizational Criteria
● The successful management of patients with thoracic
problems, particularly those with thoracic malignancies, by involving a multidisciplinary team approach
with the use of standard diagnostic and treatment
protocols and the involvement of a variety of surgical
and nonsurgical specialists.
● For level 1 units, a designated thoracic unit with
identified leadership and accountability.
● A system of regular review of multidisciplinary patient
management (eg, multidisciplinary clinics, clinical
rounds, educational rounds, morbidity and mortality
review, and formal ongoing outcome measurements
and quality assurance) is essential for the achievement
of optimal patient outcomes.
● Participation in regional and provincial integrated networks of care as outlined in the Cancer Care Ontario
Provincial Cancer Plan (2004) to facilitate patient access, consultation, referral, quality improvement, and
continuing professional development.
● Infrastructure support for participation, and the participation of patients in clinical research in thoracic
care, both in local and national studies.
In conclusion, the expert panel on thoracic surgical
oncology created standards of practice for the delivery of
thoracic surgical oncology as they pertain to the Ontario
healthcare system, but also with applicability to other
health single-payer tax-based healthcare systems as well.
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The panel concluded that the benefits associated with the
implementation of thoracic cancer surgery standards
should result in increased regionalization, improved processes of care, and better patient outcomes.
Because the optimum organization of thoracic surgical
oncology services does not lend well to a structured
investigation, there was little definitive evidence for the
basis of the development of the standards of care. Thus,
our strategy focused on transparent expert consensus
opinion, a rigorous document development process, and
an external review of practitioners and administrators
across Ontario.
The standards were developed to provide useful guidance to the regional planning authorities, hospital chief
executive officers, cancer organizations, as well as surgeons and other practitioners in the planning of integrated cancer services, and are currently being implemented in Ontario, Canada.
Work based on this systematic review and standards document
was sponsored by Cancer Care Ontario, the Program in Evidence-Based Care, and the Ontario Ministry of Health and
Long-Term Care.
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21.
22.
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Appendix
Expert Panel on Thoracic Surgical Oncology
Ian Macmillan, MD, Ontario Association of General Surgeons,
St. Catharines, Ontario; John Dickie, MD, Peterborough Regional Health Centre, Peterborough, Ontario; Donna Maziak,
MD, The Ottawa Hospital, Ottawa, Ontario; Peter Dixon, MD,
Durham Regional Cancer Centre, Oshawa, Ontario; Brendan
Mullen, MD, Mount Sinai Hospital, Toronto, Ontario; Bill Evans,
MD, Juravinski Cancer Centre, Hamilton, Ontario; Kenneth
Gehman, MD, Thunder Bay Regional Health Sciences Centre,
Thunder Bay, Ontario; Narinder Paul, MD, University Health
Network–Princess Margaret Hospital, Toronto, Ontario; Michael
Humer, MD, Canadian Association of Thoracic Surgeons, Vancouver, British Columbia; Kevin Smith, MD, St. Joseph’s Healthcare, Hamilton, Ontario; Richard Inculet, MD, London Health
Sciences Centre, London, Ontario; Donald Jones, MD, Credit
Valley Hospital, Mississauga, Ontario; Shaf Keshavjee, MD,
University of Toronto–Toronto General Hospital, Toronto,
Ontario.
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