Improving the lung cancer resection rate in the US Department of Veterans Affairs Health System

BACKGROUND: The optimal treatment for non-small-cell lung cancer (NSCLC) is surgical resection; however, most patients are ineligible because of advanced disease. Although resection rates of 25%, have been reported nationally, rates in the Veterans Affairs (VA) system appear lower, perhaps because of limited access to specialized care. We hypothesized that, since the introduction of a specialized Lung Mass Clinic in 1999, the resection rate at the Birmingham VA Medical Center would be comparable with US benchmarks. We also sought to identify the medical and nonmedical factors that influenced the use of surgery. PATIENTS AND METHODS: We reviewed the electronic medical records of all veterans seen in the Lung Mass Clinic from 1999 to 2003 and identified patients with NSCLC. Demographics, comorbidities, diagnostic methods, times to diagnosis/resection, and postoperative survival were recorded. Reasons for nonresection were documented and tabulated, and differences between the resected and nonresected subgroups were examined. RESULTS: One hundred fifty-six patients with NSCLC were identified, and 31 (20%) underwent resection. There were no differences in age, ethnicity, or sex between those undergoing resection and those denied surgery. Patients who underwent resection were less likely to have chronic obstructive pulmonary disease and had better pulmonary function. Eighty-four percent of those who did not undergo resection had advanced disease, poor pulmonary function, or had refused therapy. Although the median time to resection was longer than expected (104 days), overall survival was comparable with other reports (65% at 3 years). CONCLUSION: Since the inception of the Lung Mass Clinic, the resection rate at Birmingham VA Medical Center has improved. The primary limitation to resection was late presentation and not preoperative delays.