Study Examines Follow-Up For Lung Cancer Surgery

Using national data, surgeons Benjamin Kozower, MD, MPH, right, Bryan Meyers, MD, MPH, left, and colleagues are performing comparative effectiveness research to improve outcomes for lung cancer patients.

After lung cancer surgery, effective surveillance is critical, both to watch for recurrence and to reduce patient anxiety. Yet few research studies have explored the best approaches for this follow-up.

To fill the information gap, Benjamin Kozower, MD, MPH, who recently joined the Section of General Thoracic Surgery, leads research on the follow-up of 10,000 lung cancer patients. He began with data gathered through a special study of the American College of Surgeons National Cancer Database, in which hospital registrars recorded whether patients survived five years after surgery or at what point they had died during that span. Through the registrars, Kozower also obtained inpatient and outpatient records, imaging and biopsy reports, which he examined to determine the impact of follow-up intensity on treating a recurrence.

“Most lung cancer patients and their doctors think that the more frequently they are seen, the better they do,” says Kozower. “Unfortunately, that’s not necessarily true. If lung cancer recurs, most patients do very poorly. But these surveillance visits require a lot of time, cost and worry for patients and sometimes uncover findings that turn out not to be cancer.”

Kozower and colleagues at the University of Virginia are analyzing their data to determine the best follow-up schedule. They also hope their efforts encourage the collection of additional patient data into the National Cancer Database as a resource for future comparative effectiveness research.

Kozower, supported by the Patient Centered Outcomes Research Institute, plans to incorporate patient-reported outcomes — patients’ own descriptions of their health status — into routine cancer surveillance visits and determine what outcomes to expect at various intervals after lung cancer surgery. He also would like to integrate patient-reported outcomes into the Society of Thoracic Surgeons database, which he chairs. These outcomes will be critical when comparing surgery with non-operative therapy for lung cancer.

Colleagues Bryan Meyers, MD, MPH, the Patrick and Joy Williamson Professor of Surgery and chief of thoracic surgery, and thoracic surgeon Varun Puri, MD, MSCI, are involved in similar research. Kozower trained under Meyers and credits his mentorship as one reason for his interest in the field.

“I take care of about 500 patients a year, but my ability to do comparative effectiveness research has the potential to reach thousands, or hundreds of thousands, of patients,” he says.


Varun Puri, MD, MSCI, a thoracic surgeon, and cardiothoracic surgeon Nabil Munfakh, MD, are the first in the division to perform robotic lung removal surgery. They perform the cases at Christian Hospital. Advocates of robotic lung removal say the procedure allows for more precise lymph node removal when compared with video-assisted thoracic surgery (VATS) lobectomy.

Thoracic surgeons and radiation oncologists at Washington University are studying new ways to counsel each lung cancer patient on selecting their best therapy. The research builds on a pilot project by Washington University biostatistics graduate student Kathleen Keogan. Rather than providing survival data drawn from broad patient populations, the new program provides each patient with survival rates for various forms of therapy experienced by patients whose ages and medical characteristics are most like the counseled patients themselves. In related work, these physicians have published numerous studies comparing the effectiveness of surgery and radiation therapy in high-risk, early stage lung cancer patients.

In patients with esophageal cancer and positive lymph nodes, chemotherapy typically is given before removal of the esophagus; the benefit of giving chemotherapy after surgery is controversial. Section Chief Bryan Meyers, MD, MPH, was senior author of a study published in the Annals of Thoracic Surgery showing that patients who received chemotherapy for positive nodes after surgery did better and lived longer. More studies are under way.