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Diagnosing & Staging Esophageal Cancer

Diagnosing & Staging Esophageal Cancer

The overall 5-year survival rates for esophageal cancer are less than 15%. Although esophagectomy has been the traditional gold standard for early stage disease, optimal treatment for localized disease has generated debate in light of the overall poor survival rate. In 2013, the Society of Thoracic Surgeons (STS) published a set of clinical practice guidelines for the diagnosis and treatment of localized esophageal cancer in Annals of Thoracic Surgery. “The guidelines are the first of a series by the thoracic surgical community to use evidence-based practices for evaluating and treating these complex patients,” says Thomas K. Varghese Jr., MD, MS, who was the corresponding author of the STS guidelines. “They set a precedent for surgeons to play a pivotal role. Diagnosing and staging are critical steps in the decision-making process when selecting optimal therapy.” The recommendations were developed to help clinicians deliver evidence-based best practices for all patients at all times. Important Recommendations on Esophageal Cancer A key recommendation in the STS guidelines is that CT of the chest and abdomen or PET-CT are recommended tests for staging locoregionalized esophageal cancer. In addition, endoscopic ultrasonography is recommended for patients who are surgical candidates to determine the locoregional extent of disease, but diagnostic endoscopic mucosal resection should be considered for a more accurate diagnosis in early stages. Flexible endoscopy with biopsy is the diagnostic test of choice in order to determine the presence and location of the cancer and to biopsy any suspicious lesions. The location and length of the tumor, the extent of circumferential involvement, and the degree of obstruction should also be noted. The guidelines recommend that the...

Age & Complications in Esophageal Cancer Surgery

Patients aged 50 or younger undergoing esophagectomy for cancer appear to have shorter ICU stays, fewer complications, and lower overall treatment costs than older patients. A Seattle-based investigation found that the younger patients presented with a similar stage and overall survival rates when compared with older patients, but tended to have longer delays to presentation. Abstract: Annals of Thoracic Surgery, November...

Hospital Volume & Mortality: Trends in High-Risk Surgery

A growing number of studies have reported inverse relationships between hospital volume and surgical mortality, with lower mortality seen in higher-volume institutions. There have been numerous efforts to concentrate selected operations at high-volume hospitals. The Leapfrog Group, a consortium of large corporations and public agencies that purchase healthcare for their employees, has been among the most prominent advocates of volume-based referrals. Private payers and professional organizations have also established minimum-volume standards as part of Centers of Excellence accreditation programs for a variety of operations. “Despite these efforts, little is known if they have altered referral patterns for high-risk surgery,” says Jonathan F. Finks, MD. Throughout the country, more and more surgical patients are being treated at high-volume hospitals, but the net effects on operative mortality can be difficult to predict. Dr. Finks says, “for example, hospital volume of a few high-risk cancer procedures, such as pancreatectomy, appears to be a strong predictor of operative risk. At the same time, relationships between surgical volume and outcome are much weaker for most operations.” “Some strategies that appear to be of particular benefit include use of operating-room checklists, outcomes measurement and feedback programs, and national and regional collaborative quality-improvement initiatives.” In a study published in the June 2, 2011 New England Journal of Medicine, Dr. Finks and colleagues at the University of Michigan used data from national Medicare claims to evaluate trends in the use of high-volume hospitals for major cancer resections and cardiovascular surgery. The investigators identified patients (aged 65 to 99) who underwent one of the following cancer and cardiovascular operations from 1999 through 2008: 1) esophagectomy, 2) pancreatectomy, 3) lung...
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