More than half of the 60,000 individuals who undergo surgery for lung cancer in the US each year die of lung cancer within 5 years. Although whether, or not, cancer has spread to their lymph nodes is the strongest predictor of survival in this population, 46% of patients with no lymph node metastasis die within 5 years. We have shown the existence of a gap between recommended lymph node examination of lung cancer and actual practice. In our existing grant, R01 CA 172253, we successfully deployed routine use of a lymph node specimen collection kit to improve the quality of lymph node collection during surgery. We now want to extend this quality improvement work to overcome the demonstrated inadvertent discarding of most cancer-containing lymph nodes present within lung resection specimens. Indeed 29% of all patients and 12% of patients ?without nodal metastasis? have discarded lymph nodes involved with cancer. Such patients have a much higher than expected death rate within 3 years. We conservatively estimate that 4800 ? 6200 lives would be saved annually if we raised the quality of pathologic nodal staging to achieve the 5-year survival rates of Japanese patients. We have developed an improved method of retrieving lymph nodes within the lungs and now want to study the process of implementing this new method in a diverse group of 8 community-based pathology practices working within 13 hospitals in 7 different healthcare systems in 5 contiguous Dartmouth Hospital Referral Regions in 3 states with the highest US lung cancer mortality rates: North MS, Eastern AR, Western TN. From our prior work, we hypothesize that successful implementation of this novel pathology gross dissection process will eliminate the practice of mistakenly discarding lymph nodes without examination. Our objective is to study the process of implementing this practice change in a diverse group of pathology practices as a step toward future national and international dissemination. We propose to achieve this through the following Specific Aims: 1.) Train pathology staff on our novel lung dissection protocol using a stepped-wedge cluster study design; 2.) Use the RE-AIM framework to study the implementation process; 3.) Perform a cost- effectiveness analysis of the new method. Our study will demonstrate the practical possibility of significantly improving lung cancer patients? long-term survival by accurately sorting them into risk groups for various levels of post-operative management; generate new knowledge about contextual factors that influence the spread of new, improved clinical care standards; and help institutions learn how to achieve evidence-based quality guidelines for staging lung cancer. Our ultimate goal is to improve lung cancer patients? survival by improving their placement into correct risk categories, so that those at residually high risk can be identified and given the life-saving treatments they need. 1

Public Health Relevance

This is a quality improvement project designed to study the implementation of an improved pathologic gross dissection protocol for retrieving lymph nodes from lung cancer resection specimens. The goal is to eliminate the common practice of inadvertently discarding lymph nodes with metastasis by improving the thoroughness of intrapulmonary lymph node retrieval. This study uses a collaborative, pathologist-centered approach to eliminate a well-characterized outcome disparity in a high lung cancer incidence and mortality region of the US and extends a pre-existing project to improve surgical treatment of early stage lung cancer.

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National Cancer Institute (NCI)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Baptist Memorial Hospital - Tipton
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Ray, Meredith A; Faris, Nicholas R; Smeltzer, Matthew P et al. (2018) Effectiveness of Implemented Interventions on Pathologic Nodal Staging of Non-Small Cell Lung Cancer. Ann Thorac Surg 106:228-234
Osarogiagbon, Raymond U; Ray, Meredith A; Faris, Nicholas R et al. (2017) Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria. Ann Thorac Surg 103:1557-1565
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Smeltzer, Matthew P; Faris, Nicholas; Yu, Xinhua et al. (2016) Missed Intrapulmonary Lymph Node Metastasis and Survival After Resection of Non-Small Cell Lung Cancer. Ann Thorac Surg 102:448-53
Osarogiagbon, Raymond U; Lin, Chun Chieh; Smeltzer, Matthew P et al. (2016) Prevalence, Prognostic Implications, and Survival Modulators of Incompletely Resected Non-Small Cell Lung Cancer in the U.S. National Cancer Data Base. J Thorac Oncol 11:e5-16
Osarogiagbon, Raymond U (2016) Strategic approach to minimally invasive mediastinal nodal staging-a brave new world? Lancet Respir Med 4:926-927

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