Patient Reported Outcomes and Their Relationship with Lung Cancer Surgery Outcomes Open Access

Abstract

Introduction: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient reported outcomes (PRO) are an ideal method for measurement of pre- and post-operative QOL, and physical functioning. There is little understanding of the relationship between PRO, clinical comorbidities and post-operative outcomes after lung cancer surgery. We hypothesize that age and poor pulmonary function will predict worse postoperative PRO. Additionally, we hypothesize that worse higher preoperative physical function PRO will be associated with greater risk of postoperative complication and prolonged length of stay (LOS).

Methods: PRO surveys assessing multiple domains including physical function and pain intensity were generated using instruments from the NIH Patient Reported Outcome Measurement Information System (PROMIS). PRO surveys were administered to patients undergoing minimally-invasive lung cancer resections at the preoperative, one and six month postoperative time points. Data were collected and merged with our institutional Society of Thoracic Surgeons database for clinical data. Mixed-effects regression models were created to assess the impact of clinical variables on changes in PRO scores from baseline to one and six months postoperative. Poisson regression models were constructed to estimate the association between the LOS and PROMIS physical function, adjusting for procedure, age, gender, and race.

Results: A total of 123 patients underwent a thoracoscopic lung resection for cancer. When comparing clinical variables with changes in PRO after surgery, lower diffusing capacity of the lung for carbon monoxide (DLCO) was associated with significantly worse physical function (p<0.01) and greater pain intensity scores (p<0.01) at 6 months. No other clinical factor was associated with significant differences in postoperative pain or physical function scores. Among patients who had a post-operative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (p-value=0.006). LOS increased by 18% for every 10-point decrease in physical function T-score. Among patients without complications, T-score was not associated with LOS (p=0.86).

Conclusions: These results can be of significant utility in preoperative counseling for patients with low DLCO and physical function scores. These findings can be used to identify patients who may experience greater declines in QOL after surgery, greater resource utilization, and who may benefit from further risk-reduction measures.

Table of Contents

Section                                                                                                                           Page

Introduction…………………………………………………………….………………….1-3

Background………………………………………………………………………………....4-6

Specific Aims and Hypotheses…………………………………………………………7

Methods……………………………………………………………………………………..8-10

           Study Population…………………………………………………………………....8

           PROMIS Survey………………………………………………...…………………...9-10

           Statistical Analysis………………………………………………………………....10

Results……………………………………………………………………………………....11-15

Discussion………………………………………………………………………………....16-21

           Limitations…………………………………………………………………………...20

           Future Directions………………………………………………………...………...21

Conclusions……………………………………………………………………………..…22

References………………………………………………………………………………….23-26

Figures……… ……………………………………………………………………………...27-37

Figure 1:  Patient reported outcomes measured using PROMIS from our

                  initial pilot study of 123 patients…………………………………………27

Figure 2:  Patient reported physical function in patients treated with

                  video-assisted thoracic surgery versus open thoracotomy…………28

Figure 3:  CONSORT Flow diagram detailing patient enrollment……….....…29

Figure 4:  Patient-reported physical function and pain scores by DLCO

                  above and below 50%, as measured by PROMIS…..……………….…30

Figure 5:  Patient-reported physical function and pain scores by age

                  above and below 50%, as measured by PROMIS.………………………31

Figure 6:  Patient-reported physical function and pain scores by FEV1

                 above and below 50%, as measured by PROMIS……………………..…32

Figure 7: Patient-reported physical function and pain scores by Zubrod

                  score of 0 or 1, as measured by PROMIS………………………………….33

Figure 8: Scatter plot of correlation between diffusing capacity of the lungs

                  for carbon monoxide (DLCO) with physical function T-scores….....34

Figure 9: Scatter plot of correlation between diffusing capacity of the lungs

                  for carbon monoxide (DLCO) with pain intensity T-scores………….35

Figure 10: Frequency distribution table showing the incidence of

                    complications (Y-axis) by decile of preoperative physical function

                    T-score (X-axis)……………...............................................…………..36

Figure 11: The correlation between preoperative physical function T-score

                    (X-axis) and the length of stay (Y-axis)………………………………….37

Tables………………………………………………………………………………………....38-45

Table 1: Baseline Study Population Characteristics (n=123)……………………..38

Table 2: The association of baseline characteristics with preoperative

                PROMIS physical function T-score…………………………………………..39

Table 3: Association of baseline characteristics with preoperative

               pain intensity PROMIS T-score….…………………………………………….40

Table 4: Longitudinal analysis of changes in patient-reported physical

                function after surgery ……………………………………………………………41

Table 5: Longitudinal analysis of changes in patient-reported pain

                intensity after surgery…………………………………………………………….42

Table 6: Incidence of complications……………………………………………………..43

Table 7:  Association of length of stay (LOS) and complication status………….44

Table 8: Association of mean length of stay (days) and baseline

                preoperative PROMIS physical function T-Score………………………...45

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research
Degree	M.S.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Surgery
Keyword	Patient reported outcomes Lung cancer Post-operative outcomes Quality of life
Committee Chair / Thesis Advisor	Matthew Magee, Emory University
Committee Members	Felix Fernandez, Emory University Jose Binongo, Emory University

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