Improving pathologic nodal staging of resected lung cancer

在美国每年接受肺癌手术的60，000人中， 5年内患癌尽管癌症是否已经扩散到他们的淋巴结是最强的 在这一人群中，46%的无淋巴结转移患者在5年内死亡。我们 已经表明肺癌的推荐淋巴结检查和实际淋巴结检查之间存在差距。 实践在我们现有的资助中，R 01 CA 172253，我们成功地部署了常规使用淋巴结 标本采集包，以提高手术中淋巴结采集的质量。我们现在要扩展 这一质量改进工作，以克服已证实的无意丢弃大多数含癌 肺切除标本内存在淋巴结。事实上，29%的患者和12%的患者没有 “淋巴结转移”已经丢弃了与癌症有关的淋巴结。这类患者的发病率远高于 3年内的预期死亡率。我们保守估计，4800 - 6200人的生命将得到挽救。 如果我们提高病理淋巴结分期的质量以达到日本人的5年生存率， 患者我们已经开发了一种改进的方法，在肺部内取出淋巴结，现在想 研究在一个由8名社区病理学人员组成的多元化小组中实施这种新方法的过程 在5家相邻的达特茅斯医院的7个不同医疗保健系统的13家医院内工作 美国肺癌死亡率最高的3个州的转诊地区：北MS，东AR，西 TN.从我们以前的工作，我们假设，成功实施这种新的病理总 清扫过程将消除未经检查而错误丢弃淋巴结的做法。我们 目的是研究在不同的病理学实践中实施这种实践改变的过程 作为未来国内和国际传播的一步。我们建议透过 具体目标：1.）对病理学工作人员进行使用阶梯楔的新型肺剥离方案培训 聚类研究设计; 2.）使用RE-AIM框架研究实施过程; 3.）执行成本- 新方法的有效性分析。我们的研究将证明， 通过准确地将肺癌患者分为不同水平的风险组，提高肺癌患者的长期生存率 术后管理;产生关于影响传播的背景因素的新知识 新的、改进的临床护理标准;并帮助机构学习如何实现以证据为基础的质量 肺癌分期指南。我们的最终目标是通过提高肺癌患者的生存率， 将其归入正确的风险类别，以便能够识别剩余高风险人群， 他们需要的救命治疗 1

More than half of the 60,000 individuals who undergo surgery for lung cancer in the US each year die of lung cancer within 5 years. Although whether, or not, cancer has spread to their lymph nodes is the strongest predictor of survival in this population, 46% of patients with no lymph node metastasis die within 5 years. We have shown the existence of a gap between recommended lymph node examination of lung cancer and actual practice. In our existing grant, R01 CA 172253, we successfully deployed routine use of a lymph node specimen collection kit to improve the quality of lymph node collection during surgery. We now want to extend this quality improvement work to overcome the demonstrated inadvertent discarding of most cancer-containing lymph nodes present within lung resection specimens. Indeed 29% of all patients and 12% of patients ‘without nodal metastasis’ have discarded lymph nodes involved with cancer. Such patients have a much higher than expected death rate within 3 years. We conservatively estimate that 4800 – 6200 lives would be saved annually if we raised the quality of pathologic nodal staging to achieve the 5-year survival rates of Japanese patients. We have developed an improved method of retrieving lymph nodes within the lungs and now want to study the process of implementing this new method in a diverse group of 8 community-based pathology practices working within 13 hospitals in 7 different healthcare systems in 5 contiguous Dartmouth Hospital Referral Regions in 3 states with the highest US lung cancer mortality rates: North MS, Eastern AR, Western TN. From our prior work, we hypothesize that successful implementation of this novel pathology gross dissection process will eliminate the practice of mistakenly discarding lymph nodes without examination. Our objective is to study the process of implementing this practice change in a diverse group of pathology practices as a step toward future national and international dissemination. We propose to achieve this through the following Specific Aims: 1.) Train pathology staff on our novel lung dissection protocol using a stepped-wedge cluster study design; 2.) Use the RE-AIM framework to study the implementation process; 3.) Perform a cost- effectiveness analysis of the new method. Our study will demonstrate the practical possibility of significantly improving lung cancer patients’ long-term survival by accurately sorting them into risk groups for various levels of post-operative management; generate new knowledge about contextual factors that influence the spread of new, improved clinical care standards; and help institutions learn how to achieve evidence-based quality guidelines for staging lung cancer. Our ultimate goal is to improve lung cancer patients’ survival by improving their placement into correct risk categories, so that those at residually high risk can be identified and given the life-saving treatments they need. 1