The pre-operative evaluation of patients with lung carcinoma being considered for resection has been outlined in a number of published guidelines, including those from the American College of Chest Physicians (ACCP) (Chest Supplement 2003). The current investigation was designed to assess the utilization of these recommendations by thoracic surgeons.
A web-based survey of 13 questions utilizing the ACCP step-wise physiologic approach to these patients was e-mailed to all US members of the “Society of Thoracic Surgeons”.
The response rate was 10% (n=243). The geographical location and practice type were evenly distributed. The majority of surgeons (99%) routinely requested pre-operative pulmonary function testing (PFT). Most (82.6%) proceed with resection if the PFT is normal (FEV1 >60%), while 17.4% required more investigations. If the FEV1<60%, five physicians (2.1%)declined surgery, while the remainder proceed with further secondary evaluation including split function V/Q scan (60.3%), stair climbing (18%), cardio-pulmonary exercise testing (CPET) (14.2%) or walk test (5.4%). Abnormal results prompted further testing in 85.2% of respondents, while 14.8% declined surgery. When responses were stratified based on the surgeons’ primary hospital affiliation, community (n=94) vs. teaching community and university (n=146), those without an academic affiliation withhold surgical resection based on abnormal secondary testing (29.5% v/s 15.1%, p<0.05). Similar results were found in practitioners performing fewer than 50 resections a year (n=157) as compared to those performing > 50 (n=86)(27.7% v/s 8.5%; p<0.05).
The results of this survey demonstrate that the majority of thoracic surgeons are following the ACCP guidelines for pre-operative evaluation of patients with lung carcinoma. However, surgeons in the community, and those performing fewer resections more frequently decline surgery before completing the recommended physiologic assessment.
For some patients with lung carcinoma surgical resection remains the best option for cure. Given this factor, a complete pre-operative physiologic evaluation should be completed before patients are declined for resection. Broader implementation of guidelines outlining this assessment, especially at the community level, may allow more patients to proceed with surgical therapy.
Naim Aoun, None.