Improving pathologic nodal staging of resected lung cancer

在美国每年接受肺癌手术的6万人中，有一半以上死于肺癌 5年内罹患癌症。尽管癌症是否已经扩散到他们的淋巴结是最强烈的 在这一人群中，46%的无淋巴结转移的患者在5年内死亡。我们 已表明推荐的肺癌淋巴结检查与实际检查之间存在差距 练习一下。在我们现有的赠款R01 CA 172253中，我们成功地部署了淋巴结的常规使用 标本采集试剂盒，以提高手术中淋巴结采集的质量。我们现在想要延长 这一质量改进工作克服了大多数含有癌症的已证明的不经意丢弃 肺切除标本内有淋巴结。实际上，29%的所有患者和12%的患者没有 “结节转移”是指丢弃了与癌症有关的淋巴结。这样的患者有远远高于 预计3年内死亡率。我们保守地估计，4800-6200人的生命将被拯救 如果我们每年提高病理结节分期的质量，以达到日本人的5年生存率 病人。我们已经开发了一种改进的方法来提取肺内的淋巴结，现在想要 在8个不同的社区病理学小组中研究实施这一新方法的过程 在5个相邻的达特茅斯医院的7个不同医疗系统的13家医院内工作的实践 美国肺癌死亡率最高的3个州的转诊地区：马萨诸塞州北部、AR东部、西部 TN.根据我们之前的工作，我们假设这个新的病理模型的成功实施 清扫过程将消除未经检查就错误丢弃淋巴结的做法。我们的 目的是研究在不同的病理实践组中实施这一实践改变的过程 作为迈向未来国内和国际传播的一步。我们建议透过 具体目标如下：1.使用阶梯式楔形物对病理工作人员进行培训，了解我们的新型肺解剖方案 整群研究设计；2.)使用RE-AIM框架研究实施过程；3)执行成本- 对新方法的有效性进行了分析。我们的研究将证明显著的实际可能性 准确分类不同水平的高危人群，提高肺癌患者的长期存活率 关于术后管理；产生关于影响疾病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循证质量 肺癌分期指南。我们的最终目标是通过改善肺癌患者的生存 将其归入正确的风险类别，以便那些处于剩余高风险的人可以被识别并给予 他们需要救命的治疗。 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