Abstract
Objectives:
Patient-reported outcomes (PROs) are critical tools for evaluating patients before and after lung cancer resection. In this study, we assessed patient-reported pain, dyspnea, and functional status up to 1 year post-operatively.
Methods:
This study included patients undergoing surgery for non-small cell lung cancer at a single institution (2017–2020). We collected PROs using the National Institutes of Health (NIH) Patient Reported Outcome Measurement Information System (PROMIS). Data were prospectively collected and merged with our institutional Society of Thoracic Surgery (STS) data. Using multivariable linear mixed-effect models, we compared PROMIS scores between pre-operative and several post-operative visits.
Results:
From 2017 until 2020, 334 patients underwent lung cancer resection with completed PROMIS assessments. Pain interference, physical function, and dyspnea severity scores were significantly worse 1 month after surgery (p<0.001). Pain interference and physical function scores returned to baseline by 6 months after surgery. However, dyspnea severity scores remained persistently worse up to 1 year after surgery (1-month difference 8.8 ± 1.9; 6-month difference 3.6 ± 2.2; 1-year difference 4.9 ± 2.8, p<0.001). Patients receiving a thoracotomy had worse physical function and pain interference scores 1 month after surgery compared to patients receiving a minimally invasive operation; however, there were no differences in PROs by 6 months after surgery.
Conclusions:
PROs are important metrics for assessing patients before and after lung cancer resection. Patients report persistent dyspnea for at least 1 year after resection. Additionally, patients undergoing thoracotomy initially report worse pain and physical function but these impairments improve by 6 months after surgery.
Classifications: Patient reported outcomes, lung cancer, thoracic surgery, dyspnea, pain
Graphical Abstract
Central Picture Legend
Dyspnea severity PROMIS scores following non-small cell lung cancer resection.
Introduction
Lung cancer research has traditionally focused on objective biomedical outcomes like survival and perioperative complications to compare various treatments. While these measures are important and readily available in most cancer registries, they fail to capture other subjective outcomes that are meaningful to patients. Patient-reported outcomes (PROs) are self-reported health-related quality of life (HRQOL) measures of patient physical, mental, and emotional well-being1. PROs capture symptom severity, like the degree to which post-operative pain or dyspnea affect daily activity. Unfortunately, PROs are often overlooked in most clinical settings and are rarely collected. Several organizations including the Center for Medicare and Medicaid Services (CMS) and the American College of Surgeons (ACS) have advocated for incorporating PROs into routine clinical practice2,3. The American College of Chest Physicians (ACCP) has recommended that PROs should be a routine part of all lung cancer evaluations4. The Society of Thoracic Surgery (STS) has developed a taskforce for incorporating PROs into the STS Database5,6. Despite this growing emphasis, however, PROs remain underutilized.
Several platforms exist for PROs collection1. The National Institutes of Health (NIH)-developed Patient-Reported Outcomes Measurement Information System (PROMIS) is one such platform. PROMIS holds several advantages to other PRO platforms because it is inexpensive, web-based, and widely customizable to a variety of clinical settings7–9. PROMIS has previously demonstrated utility in cardiac surgery as a predictor of long-term morbidity and quality of life10,11. Widespread, multi-insitutional collection of PROs using a common platform (like PROMIS) could allow for more robust risk prediction models to foster better patient-centered care. For example, patients who are marginal surgical candidates could be better stratified using PROs. Further validation of these measures is therefore needed in order to incorporate them into routine clinical practice.
In this study, we prospectively gathered PROMIS assessments on patients undergoing lung cancer resections at our institution. These data were then merged with our institutional STS General Thoracic Surgery Database (GTSD). Our primary aim was to describe longitudinal changes in dyspnea severity, physical function, and pain interference following surgery. We hypothesized that PROs return to pre-operative baseline values by 6 months following surgery.
Patients and Methods
We performed a prospective cohort study of all patients with non-small cell lung cancer (NSCLC) receiving an operation at a single academic institution (Barnes Jewish Hospital, St. Louis, MO). Study inclusion dates were May 2017 until March 2020. Exclusion criteria were patients less than 18 years old and patients who did not complete at least 1 PROMIS survey. Patients were also excluded if they could not read or understand English or Spanish. The Washington University School of Medicine Institutional Review Board approved this study with waiver of informed consent given the de-identified nature of the analysis (IRB #201807101, approved 8/9/2018).
PROMIS data were prospectively collected at a single outpatient clinic as part of our routine patient evaluation (Center for Advanced Medicine, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO). We had previously enhanced our PROs collection as part of a quality improvement study, through which we achieved PROMIS assessment completion in over 90% of patient visits12. Due to institutional limitations while implementing PROs collection throughout our cancer center, we were limited to collecting three PROMIS instruments. We selected physical function (PROMIS Bank v2.0), pain interference (PROMIS Bank v1.1), and dyspnea severity (PROMIS Bank V1.0) for our lung cancer patients. Each instrument was collected using the PROMIS Computer Adaptive Testing (CAT)-based software, which uses answers from previous questions to dictate the most informative set of future questions. Each CAT contains between 4–12 items and is meant to be completed in approximately 1 minute, depending on the number of questions administered5. The PROMIS Assessment Center website maintains a CAT demo software, for interested readers (https://www.healthmeasures.net/explore-measurement-systems/promis). Surveys were completed on tablet computers (iPad mini, Apple, Cupertino, CA) following patient registration13,14.
We collected data during all pre-operative and post-operative clinic visits. We then classified these visits into several time points for the purposes of this analysis. For the “pre-operative” time point, the most recent clinic visit before surgery was used; for the post-operative time points (1-month, 6-month, and 12-month), the clinic visit closest to each time point was chosen. These data were then merged with our institutional STS GTSD data to collect patient demographics, tumor-related characteristics, operation-related characteristics, and perioperative outcomes.
Our primary outcome was the change in PROMIS scores over time. PROMIS scores are standardized (so-called T scores) on a scale from 0 to 100, with a population mean of 50 and standard deviation of 10 units for each instrument9. Higher scores reflect “more” of a given domain. For example, a patient with a pain interference score of 60 has worse pain interference that is 1 standard deviation above the population mean. Minimally important differences (MIDs) – or score changes that are clinically relevant – are typically estimated to be between 2–6 points for each domain15. Prior studies have further validated physical function and pain interference scores in patients with cancer. For example, one can interpret physical function scores as follows: “within normal limits” (>50); “mild impairment” (50–35); “moderate impairment” (35–20); and “severe impairment” (<20)16. For pain interference, one can interpret scores as follows: “within normal limits” (<47.5); “mild interference” (47.5–57.5); “moderate interference” (57.5–67.5); and “severe interference” (>67.5)17.
Additional outcomes of interest included 30-day mortality, 30-day complications, and 30-day readmissions. Major complications were defined as occurrence of any of the following: pneumonia, acute respiratory distress syndrome (ARDS), bronchopleural fistula, pulmonary embolus, initial ventilator support >48 hours, respiratory failure or reintubation, tracheostomy, myocardial infarction, or unexpected return to the operating room18.
Statistical Analysis
Descriptive summary statistics were presented for demographic and clinical characteristics. For continuous variables, mean and standard deviation were presented. For categorical variables, the number and percentage of patients in each category were summarized. To account for correlations among repeated measures from the same patient, the longitudinal data were analyzed using a linear mixed-effect model to examine the change in PROMIS scores over the 4 time points19. The mixed model included the survey time point, group indicator (thoracotomy vs. minimally invasive resection; lobectomy vs. sublobar resection), and the interaction term between survey time point and group indicator. The univariable and multivariable mixed models were constructed controlling for the following covariates: age, gender, race (white vs. non-white), cigarette smoking, ASA Physical Status Classification System score (1–2 vs. 3–4), various comorbidities (diabetes, CAD), type of operation (lobectomy, segmentectomy, etc.), type of incision (VATS/robotic vs. thoracotomy), pathologic stage, discharge location, readmission status, and major complication status. Only the covariates with p value <0.3 in the univariate model were considered in the multivariable model. Through backward selection, the final multivariable model included the risk factors with p-value <0.15. The least square mean (LSM) and 95% confidence interval (CI) for PROMIS were presented at each time point. The LSM difference and 95% CI between any two time points were also provided. P-values of less than 0.05 were considered statistically significant. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).
Results
From 2017 until 2020, 334 patients receiving an operation for lung cancer were included. Completed PROMIS assessments were classified as pre-operative (n=246), 1-month post-operative (n=196), 6-month post-operative (n=113), and 12-month post-operative (n=72). An assessment of patients who were lost to follow-up is available in supplementary tables 1-3; notably, demographic and treatment-related factors did not differ significantly between patients with complete and incomplete follow-up. Patient demographics are shown in Table 1. Tumor- and operation-related characteristics along with several operative outcomes are shown in Table 2. A majority of patients underwent lobectomy (72.5%) and most operations in this cohort were performed via thoracotomy (63.5%, supplementary table 4). A slight majority of tumors were T1 on final pathology (51.2) and most tumors were adenocarcinomas (57.5%). The most common major complications (3.3%) were pneumonia (0.5%) and respiratory failure (3.0%).
Table 1.
Study Population Demographics
| Demographics | N = 334 |
|---|---|
| Age, mean (SD) | 65.5 (10.2) |
| Male (%) | 159 (47.6) |
| Race (%) | |
| White | 286 (85.6) |
| African American | 37 (11.1) |
| Other | 11 (3.3) |
| Comorbidity (%) | |
| HTN | 222 (64.5) |
| CAD | 52 (15.6) |
| CHF | 10 (3.0) |
| DM | 72 (21.6) |
| Cigarette Smoking (%) | |
| Current | 78 (23.4) |
| Former (quit >1 month before surgery) | 190 (56.9) |
| Pack Years, n, mean (SD) | 261, 45.3 (28.4) |
| ASA | |
| 1–2 | 73 (21.9) |
| 3–4 | 261 (78.1) |
ASA Physical Status Classification System score; CAD, coronary artery disease; CHF, congestive heart failure; DM, diabetes mellitus; HTN, hypertension
Table 2.
Study Population Treatment Characteristics and Complications
| Characteristics | N = 334 |
|---|---|
| Type of incision (%) | |
| Thoracotomy | 212 (63.5) |
| Minimally invasive | 122 (36.5) |
| VATS | 76 (23.6) |
| Robotic | 46 (13.8) |
| Operation (%) | |
| Lobectomy | 242 (72.5) |
| Segmentectomy | 33 (9.9) |
| Wedge | 36 (10.8) |
| Pneumonectomy | 23 (6.9) |
| Pathologic T Stage (%) | |
| T1 | 171 (51.2) |
| T2 | 95 (28.4) |
| T3 | 41 (12.3) |
| T4 | 20 (6.0) |
| Other or Unknown | 7 (2.1) |
| Pathologic N Stage (%) | |
| N0 | 238 (71.3) |
| N1 | 43 (12.9) |
| N2 | 30 (9.0) |
| Other or Unknown | 23 (6.9) |
| Pathologic M Stage (%) | |
| M0 | 328 (98.8) |
| M1 | 4 (1.2) |
| Histology (%) | |
| Adenocarcinoma | 192 (57.5) |
| Squamous | 82 (24.6) |
| Other or Unknown | 55 (16.5) |
| Outcomes | |
| Major Complication | 11 (3.3) |
| Pneumonia | 2 (0.5) |
| ARDS | 0 (0) |
| Bronchopleural fistula | 0 (0) |
| PE | 1 (0.2) |
| Initial ventilator support >48 hrs | 0 (0) |
| Respiratory failure | 10 (3.0) |
| Tracheotomy | 3 (0.9) |
| Myocardial infarction | 0 (0) |
| 30-day mortality | 4 (1.2) |
| 30-day readmission | 31 (10.0) |
ARDS, acute respiratory distress syndrome; PE, pulmonary embolism; VATS, video-assisted thoracic surgery
Estimated pre-operative and post-operative PROMIS scores from the multivariable mixed models are shown in Table 3 and Figure 1. In terms of the overall longitudinal trends, pain interference, physical function, and dyspnea severity scores changed significantly across the visits (p<0.001) and were consistently worse at 1 month following surgery (Figure 1). Pain interference (1-month difference 10.3 ± 1.5; 6-month difference 1.8 ± 1.8; 1-year difference 0.7 ± 2.1, p=0.470) and physical function (1-month difference 8.3 ± 1.3; 6-month difference 1.1 ± 1.3; 1-year difference 1.0 ± 1.6, p=0.220) scores returned to baseline by 6 months. However, dyspnea severity scores remained persistently worse up to 1 year following surgery (1-month difference 8.8 ± 1.9; 6-month difference 3.6 ± 2.2; 1-year difference 4.9 ± 2.8, p<0.001).
Table 3.
Changes in post-operative PROMIS scores compared to pre-operative scores
| Difference from Baseline* | |||||||
|---|---|---|---|---|---|---|---|
| PROMIS instrument | Pre-operative baseline* | 1-month follow-up | p-value | 6-month follow-up | p-value | 12-month follow-up | p-value |
| Dyspnea severity | 34.9 ± 1.6 | 8.8 ± 1.9 | <0.001 | 3.6 ± 2.2 | 0.001 | 4.9 ± 2.8 | <0.001 |
| Pain interference | 48.9 ± 1.3 | 10.3 ± 1.5 | <0.001 | 1.8 ± 1.8 | 0.325 | 0.7 ± 2.1 | 0.477 |
| Physical function | 46.0 ± 1.2 | 8.3 ± 1.3 | <0.001 | 1.1 ± 1.3 | 0.108 | 1.0 ± 1.6 | 0.222 |
Least square mean or least square mean differences ± 95% CI
Figure 1.
Changes in PROMIS (a) dyspnea severity, (b) pain interference, and (c) physical function scores over time (pre-operative, 1-month, 6-months, and 12-months following surgery) for patients with NSCLC undergoing surgery. For dyspnea severity and pain interference, higher scores represent worse symptoms (arrows). For physical function, higher scores represent better symptoms (arrows). Error bars represent standard error. PROMIS, Patient Reported Outcomes Measurement Information System.
PROMIS scores across the 4 time points for different surgical approaches (minimally invasive vs. thoracotomy) were estimated (Table 4, Figure 2). Patients receiving a thoracotomy had worse physical function scores at baseline (difference 2.3 ± 2.1, p=0.032) but similar pain interference and dyspnea severity scores. Patients who received a thoracotomy had worse pain interference (difference 2.9 ± 2.2, p=0.010) and physical function scores (3.6 ± 1.7, p<0.001) at 1 month following surgery. However, pain interference and physical function scores were similar between the two groups at 6 months and 1 year after surgery. Dyspnea severity scores did not differ significantly between patients receiving a thoracotomy or minimally invasive operation at any of the follow-up time points. Overall, there was no significant difference in PROs between groups by 6 months after surgery. There were no differences in major complications by surgical approach in this cohort (supplementary table 5).
Table 4.
Differences in PROMIS scores between minimally invasive and open operations
| Absolute Score Difference (Minimally Invasive vs. Thoracotomy)* | ||||||||
|---|---|---|---|---|---|---|---|---|
| PROMIS instrument | Pre-operative | p-value | 1-month follow-up | p-value | 6-month follow-up | p-value | 12-month follow-up | p-value |
| Dyspnea severity | 2.7 ± 3.1 | 0.096 | 1.1 ± 3.6 | 0.527 | 3.4 ± 4.0 | 0.099 | 1.2 ± 5.2 | 0.640 |
| Pain interference | 0.7 ± 2.5 | 0.588 | 2.9 ± 2.2 | 0.010 | 2.7 ± 3.0 | 0.083 | 1.4 ± 3.7 | 0.447 |
| Physical function | 2.3 ± 2.1 | 0.032 | 3.6 ± 1.7 | <0.001 | 1.1 ± 2.5 | 0.404 | 2.1 ± 3.3 | 0.216 |
Least square mean differences ± 95% CI
Figure 2.
Changes in PROMIS (a) dyspnea severity, (b) pain interference, and (c) physical function scores over time (pre-operative, 1-month, 6-months, and 12-months following surgery) for patients with NSCLC undergoing minimally invasive versus open operations. For dyspnea severity and pain interference, higher scores represent worse symptoms (arrows). For physical function, higher scores represent better symptoms (arrows). Error bars represent standard error. PROMIS, Patient Reported Outcomes Measurement Information System.
Finally, we performed a similar longitudinal analysis of PROMIS scores by resection type (lobectomy vs. sublobar resection, excluding pneumonectomy) (Table 5, Figure 3). Patients undergoing lobectomy or sublobar resection had similar baseline dyspnea severity, pain interference, and physical function scores. At 1 month following surgery, physical function scores were significantly worse in patients receiving a lobectomy (difference 2.9 ± 2.4, p=0.018); dyspnea severity and pain interference scores remained similar. At both 6 months and 1 year following surgery, there was no significant difference in PROs between patients receiving a lobectomy or sublobar resection. Dyspnea severity scores did not differ at any time point between patients receiving a lobectomy or sublobar resection.
Table 5.
Differences in PROMIS scores between lobectomy and sublobar resection
| Absolute Score Difference (Lobectomy vs. Sublobar Resection)* | ||||||||
|---|---|---|---|---|---|---|---|---|
| PROMIS instrument | Pre-operative | p-value | 1-month follow-up | p-value | 6-month follow-up | p-value | 12-month follow-up | p-value |
| Dyspnea severity | 0.8 ± 3.7 | 0.664 | 2.7 ± 4.0 | 0.192 | 3.0 ± 4.8 | 0.220 | 0.7 ± 6.8 | 0.850 |
| Pain interference | 1.9 ± 3.0 | 0.228 | 1.5 ± 2.6 | 0.251 | 0.8 ± 3.7 | 0.668 | 4.1 ± 4.6 | 0.085 |
| Physical function | 1.7 ± 2.6 | 0.198 | 2.9 ± 2.4 | 0.018 | 2.2 ± 3.0 | 0.141 | 0.3 ± 4.2 | 0.902 |
Least square mean differences ± 95% CI
Figure 3.
Changes in PROMIS (a) dyspnea severity, (b) pain interference, and (c) physical function scores over time (pre-operative, 1-month, 6-months, and 12-months following surgery) for patients with NSCLC undergoing lobectomy versus sublobar resection. For dyspnea severity and pain interference, higher scores represent worse symptoms (arrows). For physical function, higher scores represent better symptoms (arrows). Error bars represent standard error. PROMIS, Patient Reported Outcomes Measurement Information System.
Comment
In this study, we prospectively collected long-term PROs on patients undergoing lung cancer resection as part of our routine clinic evaluation. As expected, we found that dyspnea severity, physical function, and pain interference scores initially worsened in the post-operative period. While pain interference and physical function scores returned to baseline by 6 months after surgery, dyspnea severity scores remained worse even 1 year after surgery. Patients who received a thoracotomy initially reported worse pain interference and physical function scores compared to patients who received a minimally invasive operation; however, these scores improved and no differences in PROs were observed by 6 months after surgery. Finally, patients receiving a lobectomy had similar dyspnea severity scores to patients receiving a sublobar resection (graphical abstract, Figure 4).
Figure 4.
Long-term patient reported outcomes following lung cancer resection. Patients undergoing thoracotomy initially report worse pain and physical function compared to minimally invasive approaches but these impairments improve by 6 months after surgery. Additionally, patients may report persistent dyspnea for at least 1 year after resection.
Several findings should be highlighted from this study. First, while patients receiving thoracotomies initially report worse PROs (pain and physical function), this seems to be transient. Several prior studies have highlighted the importance of minimally invasive lung cancer resection. Video-assisted thoracic surgery (VATS) has been associated not only with improved outcomes20–22 but also improved quality of life (PROs)23–26. We often ignore, however, that a substantial proportion of lung cancers require a thoracotomy18. Indeed, this may drive some surgeons to struggle through a difficult operation or compromise oncologic surgical principles in an effort to maintain a minimally invasive approach.
Surgeons should be aware that even if a thoracotomy is required, PROs – particularly pain and physical function – will likely recover to baseline within a reasonable time frame after surgery. Second, patient-reported dyspnea scores were similar regardless of surgical approach (minimally invasive versus open) or extent of resection (lobectomy versus sublobar resection). Prior groups have found that sublobar resections allow for better maintenance of pulmonary function compared to lobectomy27,28. While our study did not measure post-operative pulmonary function tests, we found no difference in dyspnea severity scores in patients receiving sublobar resections compared to lobectomies. This finding may reflect that patients who receive sublobar resections have worse baseline pulmonary function, thus resulting in similar dyspnea post-operatively to those who undergo a more extensive lobectomy. It is therefore important to further define the relationship between subjective measures, like the PROMIS dyspnea severity score, and objective measures, like pulmonary function tests, in the context of lung resection.
Another finding worth noting is that patients seem to experience prolonged dyspnea following lung cancer resection. While prior studies utilizing PROMIS have not directly examined PROMIS dyspnea scores5,29, Khullar et al. reported that low baseline pulmonary function tests were associated with impaired PROs post-operatively29. Paradoxically, relatively little is known about the long-term prevalence, severity, and impact of dyspnea following pulmonary resection. Feinstein et al. found that dyspnea is relatively prevalent (reported by ~60% of patients) for up to 6 years following lung cancer resection30. Sarna et al. similarly found that as many as two-thirds of NSCLC survivors reported prolonged respiratory symptoms, including dyspnea, up to 5 years after surgery31. Similarly, it is possible that dyspnea severity could differ depending on the portion of lung removed (for example, an upper lobectomy versus a lower lobectomy). Dyspnea is an important symptom that should be discussed with patients, especially those with poor baseline pulmonary capacity.
Our study complements prior studies that have examined PROMIS scores after lung cancer surgery by providing a larger sample size and longer-term data. Khullar et al. showed that PROMIS scores generally recover to baseline by 6 months after surgery; their study, however, was limited by sample size (127 patients), length of follow-up (6 months), and lack of independent dyspnea measures5. Brown et al. similarly showed the utility of PROMIS collection following lung cancer surgery in a recent pilot study32. A growing body of additional literature has looked at various HRQOL measures following lung cancer surgery1,33. Unfortunately, most of these prior studies used several different HRQOL platforms, making direct comparisons between studies difficult.
In general, PROs are rarely collected in thoracic surgery due to a variety of barriers1,34. Our study used prospectively collected data that was ascertained as part of our routine clinic workflow without additional financial resources12. This is an important point because integrating these measures into routine practice across the United States will require widespread collection and validation from multiple institutions. Funding is finite, so finding a way to collect these data without external funding is essential for the sustainability of PROs. Thoracic surgeons should also strive to use a common platform across the field. PROMIS is one such platform that is easily accessible, widely customizable, and has been validated in several oncologic settings8,35,36. With a large enough sample size, these PROs can be integrated into risk prediction models to improve patient-centered care. For example, pre-operative physical function scores could be a critical covariate for assessing marginal surgical candidates, potentially delineating the boundary between resection or definitive radiation therapy.
The importance of PROs are being further realized by several organizations and may become a routine quality metric for reimbursement3. The American College of Chest Physicians (ACCP) recommends routine PROs collection for lung cancer patients receiving treatment4. CMS has proposed physical function measures, like the physical function PROMIS measure in our study, to become a future metric to assess hospital performance5. Further validation of these instruments is therefore important and having a widely accessible platform, like PROMIS, would facilitate widespread adoption. It is important for thoracic surgery to continue to adopt and adapt PROs given their growing emphasis from several national organizations.
This study has several limitations. First, due to institutional limitations while implementing PROs collection throughout our cancer center, we were limited to collecting three PROMIS instruments. Careful consideration of which PROMIS domains to assess is important while considering the finite resources of a routine clinic setting. We chose the three PROMIS instruments that we thought were most important for lung cancer care. Second, our study population is limited to patients who follow up with us in clinic long term. Many of our patients travel several hours for care and, when recovered from surgery, follow up closer to home with a local oncologist or pulmonologist. This likely accounts for our diminished follow up. Third, we currently only collect PROMIS data at our primary cancer center clinic in our main hospital – although we see patients at several locations. This contributes to the relatively high thoracotomy rate reported in our cohort as we tend to see more complex surgical patients at our main campus. Also, only 50% of patients in this cohort had T1N0 tumors, which likely inflates the observed thoracotomy volume further. Overall, one of the strengths of this study is that it represents prospective data that was independently collected without external funding. As additional data collection spreads out to all of our clinic sites, we hope that several of these limitations will be addressed.
Finally, the attrition of our study was suboptimal. This was due in part to the difficult nature of collecting PROs, the limitations of our single clinic in which we collect PROs, and the reality that many patients do not follow-up with a thoracic surgeon again after their initial post-operative visit (i.e., they receive surveillance closer to home37). We performed extensive analyses on the attrition in our study, including how many patients are missing in each group and at what timepoints (supplementary tables 1-3). Of note, there are minimal differences between patients who were lost to follow-up and patients with complete follow-up. Therefore, while not ideal, we do not believe that this loss of follow-up necessarily diminishes the findings of our study. Further studies analyzing PROs – particularly patient-reported dyspnea – are needed to validate our results.
In conclusion, PROs are essential measures to evaluate patients before and after lung cancer resection. Our data suggest that patients report persistent dyspnea following surgery for at least 1 year. Additionally, patients who receive a thoracotomy initially report worse pain and physical function scores but these impairments seem to be transient and improve by 6 months after surgery.
Supplementary Material
Consent
The Washington University School of Medicine Institutional Review Board approved this study with waiver of informed consent given the de-identified nature of the analysis (IRB #201807101, approved 8/9/2018).
Central Message
Patient-reported outcomes (PROs) are critical tools for assessing patients before and after surgery. Patients with lung cancer report persistent dyspnea for at least 1 year after surgical resection.
Perspective Statement
PROs are self-reported health-related quality of life (HRQOL) measures of patient physical, mental, and emotional well-being. PROs are underutilized in thoracic surgery. With wider collection, these measures can be integrated into everyday clinical practice to offer better patient-centered care.
Acknowledgements
Dr. Heiden has funding through a cardiothoracic surgery NIH 5T32HL007776–25 grant. Dr. Puri has funding through a NIH 1I01HX002475–01A2 grant.
Funding:
Funded in part by NIH 5T32HL007776–25 (BTH), VA 1 I01 HX002475–01A2 (VP)
Meeting Presentations:
AATS 101st Annual Meeting, Plenary Session Presentation
IRB:
Washington University School of Medicine #201807101, approved 8/9/2018, with waiver of informed consent given de-identified nature of the analysis
Glossary of Abbreviations
- ACCP
American College of Chest Physicians
- ACS
American College of Surgeons
- CI
confidence interval
- CMS
Center for Medicare and Medicaid Services
- GTSD
General Thoracic Surgery Database
- HRQOL
health-related quality of life
- LSM
least square means
- NIH
National Institutes of Health
- NSCLC
non-small cell lung cancer
- PRO
patient-reported outcome
- PROMIS
Patient Reported Outcomes Measurement Information System
- SE
standard error
- STS
Society of Thoracic Surgery
- VATS
video-assisted thoracic surgery
Biographies
Footnotes
Conflict of Interest: None
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