Thoracic Surgery News (Archived)

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.

The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.

"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.

Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.

The criteria outlined by CMS include:

• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.

• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.

• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.

• The heart team and hospital are also participating in a prospective, national, audited registry.

The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.

Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.

CMS also responded to comments, making some changes.

For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.

Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.

"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.

"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.

Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.

"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."

CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.

The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.

Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.

The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.

"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.

Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.

The criteria outlined by CMS include:

• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.

• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.

• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.

• The heart team and hospital are also participating in a prospective, national, audited registry.

The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.

Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.

CMS also responded to comments, making some changes.

For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.

Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.

"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.

"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.

Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.

"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."

CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.

The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.

Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.

The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.

"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.

Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.

The criteria outlined by CMS include:

• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.

• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.

• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.

• The heart team and hospital are also participating in a prospective, national, audited registry.

The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.

Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.

CMS also responded to comments, making some changes.

For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.

Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.

"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.

"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.

Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.

"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."

CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.

The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

SAN FRANCISCO - Pulmonary resection outcomes vary with respect to the kind of hospital in which the procedure is performed, particularly whether it is a teaching hospital, according to Dr. Castigliano M. Bhamidipati, of the University of Virginia Medical School, Charlottesville.

"In comparison to other hospitals, including general surgery teaching hospitals, cardiothoracic surgery teaching hospitals have lower morbidity and mortality," Dr. Bhamidipati said at the AATS annual meeting.

He and his colleagues examined the results of pulmonary resections performed at cardiothoracic (CT) teaching, general surgery (GS) teaching, nonsurgical (NS) teaching, and nonteaching (NT) hospitals.

The researchers evaluated the discharge records of nearly 500,000 adults who underwent either pneumonectomy, segmentectomy, lobar resections, or nonanatomic resections in an all-payer inpatient database for the time period between 2003 and 2009, according to Dr. Bhamidipati.

The hospital's teaching status as used in the study was determined by a linkage to the Association of American Medical Colleges’ Graduate Medical Education Tracking System.

The researchers examined patient demographics, risk factors, and hospital characteristics, and used multiple logistic regression models to examine in-hospital mortality, occurrence of any complications, and failure to rescue (death following a complication).

The mean annual percent of pulmonary resection volume among hospitals was CT (16%), GS (17%), NS (28%), and NT (39%).

The average age of pulmonary resection recipients among hospitals was similar, as were their mean number of comorbidities. The CT hospitals treated the smallest number of Medicare patients and the highest number of patients with Medicaid, a significant difference, said Dr. Bhamidipati.

He reported that the unadjusted mortality for all procedures was significantly lowest at the CT hospitals (CT: 2.6%; GS: 2.8%; NS: 3.4%; NT 3.6%).

Similarly, any complication was also least likely to occur at a CT hospital (CT: 20.5%, GS: 23.5%, NS: 24.6%, NT: 24.9%), he added.

Unadjusted procedural complications were found to be similar across hospitals, although pulmonary complications were significantly less likely to occur at CT hospitals compared with the others, according to Dr. Bhamidipati.

Following case-mix adjustment, the risk of having any complication after segmentectomy or nonanatomic resection was found to be significantly lower at CT hospitals than at the GS hospitals, he said.

In addition, among the pneumonectomy recipients, CT teaching status independently and significantly reduced the adjusted odds ratio (AOR) of failure to rescue by more than 25% compared with NS (AOR 0.34 vs. AOR 0.62).

Similarly, for the pneumonectomy patients, performance of the surgery at CT centers significantly lowered the AOR of death by more than 30% compared with GS hospitals (AOR 0.33 vs. AOR 0.69).

"These results support using CT hospital teaching status as an independent prognosticator of outcomes in pulmonary resections," concluded Dr. Bhamidipati.

Dr. Bhamidipati reported that he and his colleagues had no relevant disclosures.

Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms

"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.

As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.

–Frances Correa

Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms

"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.

As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.

–Frances Correa

Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms

"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.

As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.

–Frances Correa

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

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Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

©2006 ELSEVIER LTD. ALL RIGHTS RESERVED

Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

©2006 ELSEVIER LTD. ALL RIGHTS RESERVED

Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

©2006 ELSEVIER LTD. ALL RIGHTS RESERVED

Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

©2006 ELSEVIER LTD. ALL RIGHTS RESERVED

Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.

The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.

Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."

©2006 ELSEVIER LTD. ALL RIGHTS RESERVED

Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.

Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).

The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:

• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.

• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand exposure.

Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.

The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.

The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.

Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."

In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens. Specifically, the guidelines recommend the following:

• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.

• Excising all nodules that increase in size or become solid or part-solid during follow-up.

• Considering PET with CT for nodules 8 mm or larger at baseline.

• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.

• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.

• Counseling smokers to quit.

The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.

Dr. Reid reported having no financial conflicts of interest.