The benefits of preoperative cardiopulmonary rehabilitation in the surgical outcomes of patients with lung cancer have been well described. 31-36 Bobbio and colleagues noted that shortterm cardiopulmonary rehabilitation might improve the surgical candidacy of patients with chronic obstructive pulmonary disease. 34 Moreover, Benzo and colleagues reported that 10 rehabilitation sessions resulted in shorter chest tube time and decreased length of stay, both of which lower postoperative morbidity and cost. 33
In this study, although patients who had preoperative cardiopulmonary rehabilitation experienced diagnostic delays for reasons similar to those found for patients who did not have cardiopulmonary surgery, rehabilitation led to significant delays in treatment initiation, and more than three-fourths of patients experienced delay. This delay was hardly unexpected, but only 11 of the 18 patients who had preoperative cardiopulmonary rehabilitation underwent surgical resection. As anticipated, rehabilitation did not improve the surgical candidacy of the other patients.
Regarding staging, this study is consistent with international studies in which advanced-stage NSCLC and SCLC cases were diagnosed earlier, presumably because of the associated symptom burden. 15,20,23 These results are also comparable to those of previous VAMC studies. 24-26
The authors of this quality improvement study will apply its findings when they appoint a cancer care coordinator (nurse coordinator or clinical nurse specialist) at Dayton VAMC. The services of a cancer care coordinator have significantly reduced system delay elsewhere. The VA Connecticut Healthcare System added a cancer care coordinator in 2007, and by 2010, time from lung cancer suspicion to treatment was reduced to 55 days from 136 days in 2003. 27
Limitations
First, the study was retrospective and used a small sample from a single institution; therefore, the results may not be generalizable to other health care settings. Second, the study included a small but significant number of patients who underwent serial imaging for asymptomatic pulmonary nodules; including this subgroup in the analyses of diagnostic delay negatively affected the results. Third, the effect of delay on survival was not evaluated.
Conclusion
This quality improvement lung cancer delay study examined adherence to the diagnostic and treatment time intervals recommended by the RAND Corporation in 2000. 5 Although most of its patients received histopathologic confirmation within prespecified parameters, significant delays occurred for surgical patients, presumably as a result of extensive preoperative testing and optimization. Without improved surgical candidacy for most patients enrolled in preoperative cardiopulmonary rehabilitation, the authors urge facilities to consider alternatives to surgery. Given recent advances in SABR outcomes in early-stage NSCLC, SABR is worth considering as an upfront option in cases of equivocal performance status or early-stage NSCLC.
The authors will use information from this study as a baseline at the Dayton VAMC. Planned changes include appointment of a cancer care coordinator and increased awareness of system delay. Already under way is a follow-up study of the utility of this intervention.
Disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects— before administering pharmacologic therapy to patients.