Esophageal adenocarcinoma (EAC), the dominant subtype of esophageal cancer in developed countries, is a growing health problem, characterized by poor patient prognosis and dismal survival due to ineffective screening tools and a lack of efficacious options targeting the interception or treatment of EAC. Despite molecular advances, molecular targeting of EAC remains elusive, suggesting the need for identifying alternative targets with improved prognostic and therapeutic value. Herein, we performed RNA-sequencing analysis in EAC and Barrett’s Esophagus (BE) precursor lesions to identify isoform switching events significantly linked with all-cause and cancer-specific mortality. Patients were stratified based on histopathology alone or in combination with TP53 mutation status, the most commonly mutated gene in EAC. To gain mechanistic insight, we performed isoform-specific siRNA knockdown of two isoforms, TTLL12 and HM13, both linked to patient survival, and investigated mechanisms associated with isoform dysregulation and whether targeting specific isoforms in EAC acts synergistically to improve therapeutic potential. Isoform-specific knockdown of TTLL12 and HM13 significantly decreased the viability of two EAC cell lines, sensitized EAC cell lines to standard-of-care chemotherapy agents (paclitaxel and carboplatin) with synergy, and inhibited EAC cell migratory potential. Knockdown of the TTLL12 isoform led to activation of chaperone-mediated autophagy, which, in turn, decreased expression of CHK1 and TP53; whereas knockdown of the HM13 isoform activated the unfolded protein response and induced endoplasmic reticulum stress-induced autophagy and apoptosis. In addition, HM13 isoform knockdown increased the response to an anti-PD-L1 agent, avelumab, in EAC cells, suggesting a role for isoform switching in immunosuppression. Taken together, study results suggest that isoform switching may provide novel insight for the identification of prognostic markers and inform new potential therapeutic targets for EAC treatment or prevention.

Importance Sampling of at least 3 mediastinal and at least 1 hilar nodal stations during lung cancer resection was adopted by the American College of Surgeons (ACS) Commission on Cancer (CoC) as Operative Standard 5.8 to ensure appropriate staging, guide adjuvant systemic therapy, and potentially improve overall survival. Early assessments suggested difficulty with reaching goal hospital-level compliance rates of at least 80%. Objective The objective of this study was to compare compliance with Standard 5.8 before and after participation in the Lung NODES National Quality Improvement (QI) Collaborative. Design, Setting, and Participants This quality improvement study reports findings from a prospective national QI collaborative led by the ACS CoC, Lung NODES, which enrolled CoC-accredited programs across the US from March 2024 to December 2024. Programs actively participated in guided root cause analyses, educational webinars, peer-to-peer learning, and the development and implementation of strategies to increase compliance. Data were collected on patients aged 18 years or older undergoing curative intent lung resection. Main Outcomes and Measures Adjusted multilevel logistic regression models, with hospital as a random effect, investigated variables associated with compliance with Standard 5.8. Differences in hospital-level compliance, at baseline compared to final data collection, were assessed using Wilcoxon signed rank tests. Results Among 354 participating programs, the number of programs achieving at least 80% compliance with Standard 5.8 increased from 144 (40.7%) at baseline to 238 (67.2%) after participation. Hospital-level median compliance increased from 67.8% (IQR, 42.9%-90.0%) to 90.5% (IQR, 70.0%-100%) (P < .001). All hospital types had an increase in median compliance, with the largest absolute increase, of 37.1%, seen for community programs. On adjusted multilevel analyses, compared to baseline, lung cancer resections performed after participation were associated with increased odds of compliant lymph node assessment (adjusted odds ratio, 2.50; 95% CI, 2.19-2.86). Conclusions and Relevance Participation in the Lung NODES National QI Collaborative was associated with higher compliance with Standard 5.8 irrespective of hospital characteristics. National QI collaboratives may represent an effective large-scale approach to address gaps in the delivery of high-quality cancer care.

Objective Accurate mediastinal staging is critical for the effective treatment of non–small cell lung cancer because lymph node involvement significantly influences prognosis and therapeutic decisions. We sought to evaluate the diagnostic accuracy, limitations, and complementary roles of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), cervical mediastinoscopy, and surgical lymph node sampling in mediastinal staging of non–small cell lung cancer. Methods A systematized literature review was performed using PubMed and national guideline repositories. Studies were included if they reported or provided sufficient data to calculate the negative predictive value (NPV) for EBUS-TBNA, mediastinoscopy, or surgical lymph node sampling. Data were synthesized qualitatively across different clinical scenarios. Results The pooled (unweighted) NPV of EBUS-TBNA was 93.2% (range, 84.7%-98%). Mediastinoscopy demonstrated a pooled NPV of 93.8% (range, 78.8%-97%), with most false negatives attributable to inaccessible stations. Surgical lymph node sampling yielded a pooled NPV of 92.2% (range, 83.6%-96%) for resected nodal stations, although assessment is limited by variability across studies with inconsistent surgical approaches. These data support the need for systematic intraoperative nodal evaluation to confirm pathologic stage and inform treatment selection. Conclusions Although EBUS-TBNA is the preferred initial staging modality due to its minimally invasive nature, its diagnostic limitations warrant a low threshold for additional nodal evaluation. Systematic intraoperative lymph node evaluation at the time of surgical resection is indispensable for definitive staging, providing clinically actionable data that influences treatment decisions. Optimal staging of non–small cell lung cancer requires a multidisciplinary, individualized approach that combines modalities based on pretest probability, imaging findings, and patient factors.

BACKGROUND:Esophagectomy remains a high-morbidity operation despite advances in perioperative care. The relationship between intraoperative hemodynamic management and postoperative complications remains undefined. This study explores real-time hemodynamic management patterns and postoperative complications after esophagectomy. STUDY DESIGN:Using a paired anesthesia and surgical registry, patients undergoing elective esophagectomy at a single high-volume institution between 2015 and 2023 were analyzed. Patients were categorized by fluid-restrictive or fluid-liberal intraoperative volume strategies and vasopressor-low or vasopressor-high strategies based on cumulative dose required during the case. Additionally, anesthesiologists were characterized similarly according to their relative average fluid and vasopressor administrations. Adjusted rates of select and composite postoperative complications were compared by fluid and vasopressor strategies using multivariable logistic regression. RESULTS:Of 639 patients, 296 (46.3%) received a fluid-restrictive strategy and 343 (53.7%) received a fluid-liberal strategy. Three hundred nineteen patients (49.9%) occupied the vasopressor-low category, whereas 320 (50.1%) were in the vasopressor-high category. Across the cohort, the unadjusted leak rate was 23.2%, pneumonia 10.6%, and atrial fibrillation 32.3%. There were no significant differences in adjusted rates of complications between fluid and vasopressor groups. Patients managed by fluid-liberal anesthesiologists had higher adjusted rates of atrial fibrillation (19.6% vs 27.2%, odds ratio 1.60 [1.00 to 2.57], p = 0.049). CONCLUSIONS:Hemodynamic management during esophagectomy is variable. Intraoperative volume balance or vasopressor administration may not be associated with differential complication rates; however, further analysis is warranted. This may inform postoperative management by identifying at-risk patients for complications, thereby individualizing treatment decision-making.

BACKGROUND:Extent of resection for non-small cell lung cancer is often guided by provider discretion, with evolving evidence on comparative outcomes. Although less invasive, the oncologic adequacy of sublobar resection remains uncertain. We sought to assess the association between the extent of resection and margin positivity. METHODS:We retrospectively queried a single institution for non-small cell lung cancer patients undergoing wedge resection, segmentectomy, or lobectomy from 2021 to 2024. Operative characteristics, margin status, lymph node status, perioperative outcomes, and 2-year survival and recurrence were compared across resection types. Multivariable logistic regression assessed associations between resection type and margin positivity. RESULTS:We identified 490 patients who met inclusion criteria (wedge: 64; segmentectomy: 110; and lobectomy: 316). Patients undergoing wedge resection had a higher average number of comorbidities, whereas patients undergoing lobectomy had larger tumors. Positive margins were similar across groups (wedge: 4.7%; segmentectomy: 1.8%; and lobectomy: 4.7%; P = .400). Wedge resection had a lower average number of lymph nodes harvested as well as shorter intraoperative blood loss, operative time, and hospital stay. Overall complication rates were similar. Two-year survival and recurrence were comparable between groups. Upon multivariable analysis, the extent of resection was not associated with margin positivity. Findings were consistent in the subgroup of tumors ≤2 cm. CONCLUSION:Positive margins are infrequent and do not appear to differ by resection type. Despite fewer lymph nodes harvested, wedge resection demonstrated similar short-term recurrence and survival to anatomic resection. These findings suggest that anatomic resection may not be necessary solely to achieve negative margins and support the selective use of wedge resection in appropriately chosen patients.

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Background Anastomotic leak after esophagectomy is associated with poor conduit perfusion and cervical location. Peri-anastomotic fluid acidity (pH) has been shown to be a predictor of leak after colonic anastomosis. We hypothesized that fluid acidity, from samples collected from cervical wounds after transhiatal esophagectomy could predict anastomotic leaks. Methods A prospective pilot study of patients undergoing esophagectomy with cervical anastomosis at a single academic institution was performed. A portable, non-invasive biosensor system was attached in line between a cervical drain and standard bulb. The sensor continuously monitored drainage fluid characteristics including pH and electrical conductivity, viewed in real-time on a bedside monitor. The sensor was initiated on postoperative day (POD) 0/1 and remained attached until the clinical removal of the drain (POD 5). Cervical leaks were identified by a barium esophagogram on POD 6/7. Cervical neck infections were identified based on clinical appearance and were managed similarly to those with leaks with cervical wound packing. A Mann-Whitney U Test was utilized to complete preliminary analysis and analyze statistical significance. Results 14 men and five women with a mean age of 68.26 ± 7.77 participated. The average pH of the cervical drains was 8.68 ± 0.39. Seven patients had incomplete data due to technical issues. Of the remaining 12, 8 had no-leak and 4 had a leak and/or infection. All 12 patients had comparable pH levels during the early postoperative period. After approximately 20 hours, the pH of the leak/infection group declined sharply, while the pH for the control group began to gradually increase towards 9.0 and stabilized (Figure). The difference in the mean pH was statistically significant between 48-60 hours postoperatively with p-values of 0.0012 and 0.005 for hours 48 – 54 and 54 – 60, respectively. Between postoperative hours 48 – 54 and 54 – 60, the average pH for the healthy cohort was 8.883 and 8.959, and the average pH for the leak/infection cohort was 7.637 and 8.324, respectively. Conclusion Physiological changes associated with postoperative leaks or infections are associated with an early decline of drainage pH. A statistically significant difference in pH level was recorded between 48 – 60 hours postoperatively, days earlier than a clinical leak or infection was suggested. Further investigation into pH trends could allow for modified post-operative management to minimize the impact of leaks and/or infections on patient outcomes.

8003 Background: Air pollution contributes to increased lung cancer incidence, but whether it accelerates tumor progression, resulting in more advanced stage at diagnosis, is not well understood. Understanding environmental and social factors influencing late-stage presentation can guide targeted prevention efforts. Methods: We identified primary lung cancer cases from the National Cancer Database (NCDB; 2010–2023) across 2,803 U.S. counties. Individual-level data were linked to county-level annual averages of PM₂.₅ (μg/m³) and NO₂ (ppb). Generalized estimating equation logistic models with county-level clustering assessed associations between chronic pollution exposure and odds of advanced-stage (III–IV vs. I–II) diagnosis, adjusting for median household income and educational attainment. Pollutants were z-score standardized (mean = 0, SD = 1) and summed to create a combined Pollution Burden metric. Effect modification by histology and socioeconomic status was tested. Results: Among 1,023,140 patients (mean age 68.5 ± 10.8 years; 51.3% female), 67.1% presented with advanced-stage disease. Each standard deviation increase in PM₂.₅ was associated with 4.8% higher odds of advanced-stage diagnosis (95% CI: 3.5–6.1%; p < 0.001; Table 1). In multi-pollutant models, PM₂.₅ remained significant (OR = 1.062, 95% CI: 1.047–1.076; p < 0.001), with combined pollution burden linked to a 3.1% increase in odds (95% CI: 1.5–4.7%; p < 0.001). Low-SES communities had higher advanced-stage rates regardless of pollution exposure (69.7% vs. 63.6%; p < 0.001), equating to approximately 6,100 excess annual diagnoses. Effects varied by histology, with small cell carcinoma showing the highest advanced-stage rate (91.2%), followed by adenocarcinoma (67.3%) and squamous cell carcinoma (58.6%). Conclusions: Higher PM₂.₅ exposure and lower socioeconomic status were independently associated with later-stage lung cancer diagnosis across over 1 million cases from 2,803 U.S. counties. Low-SES communities showed 6 percentage points higher advanced-stage rates irrespective of pollution levels. These findings highlight how environmental factors that may accelerate cancer progression and social barriers to accessing care can jointly delay early-stage diagnosis. Targeted pollution control and expanded lung cancer screening in underserved communities could reduce the burden of advanced-stage disease. Odds of advanced-stage lung cancer by air pollutant exposure. Pollutant Model Mean ± SD OR 95% CI Lower 95% CI Upper P-value PM₂.₅ (μg/m³) Single-pollutant 8.17 ± 1.58 1.048 1.035 1.061 <0.001 PM₂.₅ (μg/m³) Multi-pollutant 1.062 1.047 1.076 <0.001 NO₂ (ppb) Single-pollutant 6.93 ± 3.93 1.009 0.993 1.026 0.28 NO₂ (ppb) Multi-pollutant 0.978 0.963 0.994 0.007 Combined Burden Z_PM2.5 + Z_NO2 1.031 1.015 1.047 <0.001

INTRODUCTION:Lung cancer causes the most cancer-related deaths in the United States. For patients with localized disease, expeditious treatment portends improved outcomes. This study explores relationships between patient factors and timely treatment for early-stage non-small cell lung cancer (NSCLC) in a population-based cancer registry. METHODS:All adult patients with localized NSCLC between January 1, 2015, and December 31, 2021, were identified through the Michigan Cancer Surveillance Program. Demographic and social factors were compared between treatment groups. Time-to-treatment was defined as days between diagnosis and initiation of first treatment. Multivariable Poisson regression was used to compare time-to-treatment across race, payer, and rural-urban continuum groups. Subset analysis stratifying by first treatment modality was performed. RESULTS:A total of 10,618 patients with NSCLC were included, with 4753 undergoing operative resection, 5151 undergoing radiation therapy, and 894 undergoing systemic therapy. Overall mean time-to-treatment was 59.8 d (standard deviation [SD], 34.4), with time-to-surgery 57.4 d (SD, 32.9), time-to-radiation therapy 63.0 d (SD, 35.5), and time-to-systemic therapy 53.4 d (SD, 33.7). Adjusted time-to-treatment was longer in Black patients compared to White patients (incidence rate ratio [IRR]: 1.14, 95% confidence interval [CI]: 1.13-1.15, P < 0.001), longer in Medicaid patients compared to Medicare patients (IRR: 1.07, 95% CI: 1.06-1.09, P < 0.001), and shorter in patients in suburban areas compared to urban areas (IRR: 0.95, 95% CI: 0.94-0.97, P < 0.001). Subset analysis of patients undergoing operative resection yielded similar trends. CONCLUSIONS:Sociodemographic factors, including race, payer, and geography, may influence treatment wait times for patients with NSCLC. This inspires further investigation of systems-based drivers of timely treatment and equitable cancer care.

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Background There has been a shift from CROSS (C) neoadjuvant chemoradiation to FLOT (F) perioperative chemotherapy for esophageal and gastro-esophageal junction adenocarcinomas. We hypothesized that the shift to FLOT would be associated with higher pathologic complete response rates and potentially lower rates of post-operative anastomotic leak. Methods Data for patients receiving esophagectomy for esophageal cancer from a single high-volume center were prospectively collected from Jan 2019 to Dec 2025. Patients receiving neoadjuvant care were treated primarily at non-affiliated community cancer centers in the region. Patients received a variety of surgical approaches with cervical and intra-thoracic anastomoses. Demographic data, neoadjuvant treatments, perioperative outcomes, and pathologic data related to surgery were compared using chi-squared and t-tests. Results 441patients received an esophagectomy, of which 392 had adenocarcinomas, with 260 (66%) receiving CROSS, 61 (16%) no prior treatment, 33 (8%) FLOT based therapy (5 with immunotherapy), 12 (3%) received FOLFOX based treatments and 26 (7%) had incomplete records. There was a trend towards C patients being older (65 +/- 9 yrs vs 62 +/- 9 hrs, p=0.07). There were similar rates of interrupted neoadjuvant therapy (22% C vs 15% F, p=NS). PCR (23% C vs 21% F, p=0.77) and positive margin rates (3.5% C vs 0% F, p=0.28)) were similar between groups. Of note, 36 patients with squamous cell cancer received CROSS with 19 (53%) having a PCR (Figure). Complication rates (71% C vs 58% F, p=NS), leak rates (27% C and 15% F, p=0.13), and length of stay (11+/- 8 dys C vs 10 +/-8 dys F, p=NS) were also statistically similar. Conclusion The adoption of FLOT based therapy prior to esophagectomy appears to have similar results in pathologic CR rates compared to CROSS for patients with esophageal adenocarcinomas. Complication rates, including anastomotic leak appear similar, also with similar postoperative recovery periods. In this cohort the adoption of perioperative FLOT did not result in increased adverse perioperative outcomes.

BACKGROUND:For patients with early-stage non-small cell lung cancer (NSCLC), treatment delays confer worse overall survival. The relationship between social vulnerability and time-to-treatment for NSCLC is unknown. METHODS:Using statewide cancer registry data, patients with localized (N0) NSCLC from 2015 to 2021 were identified. Social Vulnerability Index (SVI) was identified using patient place of residence. Using Poisson regression, the association of time-to-treatment and SVI was evaluated, with subgroup analyses stratifying by first treatment modality. RESULTS:10,562 patients were included. Time-to-treatment increased in each subsequent SVI quartile. Compared to the lowest quartile, patients in the highest SVI quartile had longer adjusted time-to-treatment (64.6 vs 61.0 days, IRR 1.06 (95 ​% CI 1.05-1.07), p ​< ​0.001). In subgroup analysis, patients in the highest quartile had longer time-to-treatment for all modalities. CONCLUSIONS:NSCLC patients with higher social vulnerability demonstrate longer time-to-treatment, motivating further work addressing social determinants of health to maximize population-level access to timely lung cancer care.

Objective: Private equity acquisition of hospitals performing complex operations is increasingly prevalent in the US healthcare landscape. Although comparative health outcomes for common medical conditions have been investigated, the quality of thoracic surgical care in private equity-acquired hospitals is unknown. Methods: Medicare beneficiaries, aged 65 to 99 years, undergoing elective lung resection between 2016 and 2020 were included. Private equity-acquired hospitals were identified using the Agency for Healthcare Research and Quality Health System Compendium. Postoperative outcomes, including 30-day mortality, complications, failure to rescue, readmission, and postoperative length of stay were risk adjusted and compared with nonacquired hospitals using logistic regression considering patient age, sex, comorbidities, procedure type, and year of procedure. Results: Of 144,223 beneficiaries undergoing lung resection, 11,140 (7.7%) received care at private equity-acquired hospitals. Private equity-acquired hospitals performed fewer lung resections annually (mean = 4.2) than nonacquired hospitals (mean = 10.5; P < .001). Compared with nonacquired hospitals, patients treated at private equity-acquired hospitals demonstrated higher rates of 30-day mortality (2.1% vs 1.9%, odds ratio [OR], 1.17 [1.03-1.33]; P = .019), serious complications (8.1% vs 6.8%, OR, 1.29 [1.19-1.39]; P < .001), 30-day readmission (10.6% vs 9.9%, OR, 1.08 [1.01-1.15]; P = .028), and longer postoperative length of stay (5.9 vs 5.3 days; P < .001). Failure-to-rescue rates were not significantly different (9.8% vs 9.4%, OR, 1.05 [0.90-1.23]; P = .518). Conclusions: These findings raise concern that private equity-acquired hospitals may provide lower-quality care for patients undergoing common thoracic procedures. Underlying structural factors may contribute to these differences. This motivates further investigation of specialty surgical care performed at private equity-acquired health institutions.

11101 Background: Comprehensive next-generation sequencing (NGS) is an evidence-based molecular testing modality used to identify actionable oncogenic drivers in tumor tissue, guiding therapy selection and improving survival in early-stage and metastatic non-small cell lung cancer (NSCLC). However, uptake of NGS in oncology practices varies. This study aimed to identify hospital-level variation in NGS testing adoption within a statewide quality improvement collaborative. Methods: We conducted a cross-sectional analysis of patients with clinical Stage IB-IIIA NSCLC who underwent surgical resection and clinical Stage IV NSCLC sampled in 2023 across 10 academic, community, and integrated network hospitals in a statewide cancer quality improvement collaborative. Rates of NGS testing and turnaround times between biopsy date, NGS order date, NGS result date, and first treatment time were analyzed. Subsets of patients treated at facilities with in-house molecular labs or reflex molecular testing protocols were described. Multivariable logistic regression identified demographic and clinical predictors of NGS use. In a subset of patients with EGFR or ALK mutations, we evaluated tyrosine kinase inhibitor (TKI) use across hospital sites. Results: Among 318 patients, 34.9% had clinical Stage IB-IIIA and 65.1% had clinical Stage IV lung adenocarcinoma. NGS testing was performed in 65.1% of patients, with rates ranging from 13.5% to 97.8% across sites. Facilities with in-house NGS capabilities had higher NGS rates (87.8%) compared to facilities relying on send-out testing (50.8%). Similarly, facilities with reflex molecular testing protocols demonstrated higher NGS rates (75.4%) compared to those without reflex protocols (50.4%). Among patients with EGFR or ALK mutations, 77.8% received TKI therapy, with rates ranging from 0% to 100%. Of 113 early-stage patients, 32 (28.3%) had NGS performed pre-resection, 36 (34.0%) post-resection, and 40 (37.7%) did not have NGS performed. Across all sites, the median time from biopsy to NGS order was 29 days (IQR 20–49), from order to results was 13 days (IQR 11–18), and from biopsy to treatment initiation was 42 days (IQR 31–58). Smoking status was an independent predictor of NGS use with OR 0.28 (0.13-0.61, p=0.002). Conclusions: Significant variation exists in NGS adoption across hospital sites in a statewide quality improvement collaborative. However, turnaround times were consistent across sites. These benchmarking data, combined with qualitative insights, can inform quality improvement interventions for underperforming sites.

OBJECTIVE:This study analyzes the prevalence of mistreatment among cardiothoracic surgery trainees and its association with burnout, suicidal ideation, and program attrition. METHODS:A cross-sectional national survey was conducted immediately after the 2024 Thoracic Surgery Directors Association In-Training Exam. The questionnaire consisted of multiple-choice and Likert-scale questions on trainee experiences with mistreatment (eg, identity discrimination, verbal/emotional abuse, sexual harassment). Multivariable regression was used to evaluate the association between mistreatment and a composite outcome of "trainee distress" encompassing burnout, suicidal thoughts, or program attrition. RESULTS:A total of 440 trainees from 74 programs participated (74.3% response rate). Overall, 31% identified as female, 64% identified as male, and 5% did not disclose gender. Respondents were 51% White, 23% Asian, 7% Hispanic/Latino, and 5% Black/African American. Female trainees reported higher rates of identity discrimination (56% vs 14%, P < .001), verbal/emotional abuse (46% vs 36%, P = .009), sexual harassment (14% vs 3%, P < .001), and burnout (51% vs 39%, P = .006) compared with male trainees. Sources of mistreatment included faculty, patients and their families, and other healthcare staff. Approximately 50% of trainees reported experiencing the composite measure of trainee distress. Trainees who experienced any form of mistreatment had an increased risk of experiencing the composite distress measure (69.0% vs 31.0%, risk ratio, 1.19 [95% CI, 1.11-1.28]). CONCLUSIONS:There is a high prevalence of perceived mistreatment among cardiothoracic surgery trainees, with female trainees reporting significantly more burnout, perceived discrimination, and abuse than male trainees. Perceived mistreatment is associated with trainee distress.

With the publication of CALGB 140503, an increase in wedge resections for small, peripheral non-small cell lung cancer is expected; however, a relative paucity of data exists as to what defines a high quality oncologic wedge resection. The Thoracic Surgery Outcomes Research Network (ThORN), through expert discussion, guided by review of what limited data does exist, and through use of a modified Delphi process, provides these consensus statements defining an oncologically sound, high quality wedge resection. The statements are classified into five categories: 1) Preoperative Considerations 2) Technical Aspects 3) Lymph Node Assessment 4) Margin Assessment and 5) Tissue Handling by Pathology.

11140 Background: Sampling of at least 3 mediastinal and at least 1 hilar lymph node stations during lung cancer resection was adopted by the American College of Surgeons (ACS) Commission on Cancer (CoC) as Operative Standard 5.8 to ensure appropriate staging, guide adjuvant systemic therapy, and improve overall survival. Early assessments suggested difficulty with reaching goal hospital-level compliance rates of ≥80%. The objectives of this study were to compare compliance with Standard 5.8 before and after participation in the Lung NODES national quality improvement (QI) collaborative and to identify facilitators to achieving compliance. Methods: Lung NODES enrolled 354 CoC-accredited hospitals in January 2024. Over 12 months, all hospitals actively participated in guided root cause analyses, educational webinars, peer-to-peer learning, and the development and implementation of hospital-level strategies. Baseline and post-participation surveys collected data on Standard 5.8 compliance and differences in hospital-level compliance were assessed using Wilcoxon signed-rank tests. The post-participation survey queried hospitals on facilitators to achieving compliance. Results: The number of hospitals achieving ≥80% compliance with Standard 5.8 increased from 144 (40.7%) to 238 (67.2%) from baseline to post-participation, respectively. Hospital-level median compliance increased from 67.8% (IQR 42.9-90) to 90.5% (IQR 70-100), p<0.001. All hospital types had an increase in mean absolute difference in compliance, with the largest increase seen for community hospitals (25.4%, STD 43.5) (Table). For the 114 programs that newly achieved compliance, facilitators included surgeon buy-in (83.3%), proactive specimen labeling (76.3%), and multidisciplinary communication (73.7%). Conclusions: Participation in Lung NODES was associated with higher compliance with Standard 5.8 irrespective of hospital type, suggesting that national QI collaboratives may represent an effective large-scale approach to address gaps in cancer care delivery. Operative standard 5.8 compliance by hospital type at baseline and after participation in Lung NODES. Hospital Type Baseline Compliant Programsn (%) Final Compliant Programsn (%) Baseline Compliance Median (IQR) Final Compliance Median (IQR) Absolute Difference in ComplianceMean (STD) Academic N= 50 19 (38.0) 38 (76.0) 68.7 (35.0-90.0) 88.9 (80.0-100) 20.0 (29.8) Community N=32 10 (31.3) 21 (65.6) 56.3 (23.6-83.8) 93.4 (66.7-100) 25.4 (43.5) Comprehensive Community N=147 55 (37.4) 97 (66.0) 65.0 (42.9-89.5) 91.7 (66.7-100) 17.5 (30.3) Integrated Network N=102 51 (50.0) 68 (66.7) 78.6 (50.0-92.2) 90.2 (70.6-100) 12.8 (29.0) Other N=23 9 (39.1) 14 (60.9) 69.0 (40.0-81.7) 84.6 (60.0-100) 13.2 (35.1)

Importance Growing trends in private equity acquisition of acute care hospitals in the US have motivated investigations into quality of care delivered at these health centers. While some studies have explored comparative outcomes for high-acuity medical conditions, care trends and outcomes of complex surgical procedures, such as esophagectomy, at private equity-acquired hospitals is unknown. Objective To compare structural characteristics and postoperative outcomes following esophagectomy between private equity-acquired and nonacquired health centers. Design, Setting, and Participants This retrospective cohort study included Medicare beneficiaries aged 65 to 99 years who underwent elective esophagectomy at US health centers between January 1, 2016, and December 31, 2020. Health centers were designated as private equity acquired using the Agency for Healthcare Research and Quality Compendium of US Health Systems. Data were analyzed between October 15, 2023, and March 30, 2024. Exposure Patient cohorts were created based on whether they received care at private equity-acquired or nonacquired health centers. Main Outcomes and Measures The main outcome was 30-day postoperative complications, mortality, failure to rescue, and readmission using summary statistics and multivariable logistic regression. Results A total of 9462 patients (mean [SD] age, 72.9 [5.6] years; 6970 male [73.7%]) underwent esophagectomy during the study period, with 517 (5.5%) receiving care at private equity-acquired institutions. Annual procedure volume was lower at private equity-acquired hospitals vs nonacquired hospitals (median, 2 [IQR, 1-4] vs 7 [IQR, 3-15] procedures per year). Compared with patients treated at nonacquired hospitals, patients treated at private equity-acquired hospitals had significantly higher 30-day mortality (8.1% [95% CI, 5.8%-10.3%] vs 4.9% [95% CI, 4.5%-5.3%]; odds ratio [OR], 1.82 [95% CI, 1.25-2.64]; P = .002), any complications (36.6% [95% CI, 32.9%-40.3%] vs 30.1% [95% CI, 29.2%-30.9%]; OR, 1.46 [95% CI, 1.18-1.80]), serious complications (17.5% [95% CI, 14.5%-20.6%] vs 14.3% [95% CI, 13.7%-15.0%]; OR, 1.34 [95% CI, 1.03-1.77]; P = .03), and failure to rescue (5.9% [95% CI, 3.9%-7.9%] vs 3.4% [95% CI, 3.1%-3.8%]; OR, 1.86 [95% CI, 1.22-2.84]; P = .004). Conclusions and Relevance These findings suggest that patients who undergo esophagectomy at private equity-acquired hospitals may be at risk for worse outcomes. Further understanding of the drivers of these outcomes is needed to improve performance and inform policy pertaining to care allocation for select surgical conditions.

e23246 Background: Next-generation sequencing (NGS) testing is used to identify driver mutations to guide selection of therapy in early-stage and metastatic non-small cell lung cancer (NSCLC). However, uptake into oncology practice has varied. The objective of this study was to identify practice patterns and barriers to NGS testing. Methods: We conducted a convergent mixed-methods analysis of oncology clinicians/stakeholders across 10 academic and community hospitals participating in a statewide cancer quality improvement (QI) collaborative. We distributed a survey asking about local practice patterns around NGS testing. We conducted semi-structured focus groups/interviews of oncology clinicians, asking about barriers to NGS use, which were analyzed using thematic analysis. We triangulated the data to develop a QI toolkit bundle. Results: A total of 45 survey responses and 17 focus groups/interviews of 37 participants were collected. Among the 10 participating hospitals, 5 (50.0%) hospitals used reflex testing protocols, 3 (30.0%) had in-house molecular labs, and 3 (30.0%) had both reflex testing protocols and in-house molecular labs. From survey responses, 40% of medical oncologists reported not having NGS results available at the time of consultation at least 50% of the time. Barriers to NGS testing included the need for repeat tissue sampling due to insufficient specimen yields, long turnaround times of NGS results leading to treatment decisions being made prior to having NGS results, and fragmented coordination of tissue specimen acquisition or NGS results from outside facilities. Facilitators to NGS testing included use of concurrent liquid biopsy, integration of results into the electronic health record, rapid onsite evaluation (ROSE) to assess tissue adequacy, and use of reflex NGS testing protocols. For early-stage NSCLC patients, barriers to NGS testing included varied clinical stage indications for performing NGS testing (eg: stage-agnostic versus only locally advanced patients) as well as non-standardized use of molecular testing platforms due to insurance or clinician preference. Process measures, such as quantity not sufficient (QNS) rates, were often not known by proceduralists or pathologists. Domains of resources highlighted in the QI toolkit bundle include guidance on patient selection for NGS testing, best practices on tissue collection protocols to reduce need to re-biopsy, guidance on clinical data intake, and guidance on prospective data collection for process improvement. Conclusions: In a statewide QI collaborative, hospital-level variation exists in NGS testing due to non-standardized and decentralized diagnostic testing processes and lack of clinical data collection for appropriate process improvement. These data informed development of a QI toolkit bundle used for locally tailored QI interventions.

Objective:. We studied a collaborative-wide quality improvement project (CQIP) focused on improving postdischarge venous thromboembolism (VTE) chemoprophylaxis adherence. We aimed to identify patient-level characteristics associated with adherence, evaluate differences in adherence rates among participating hospitals, and assess facilitators and barriers to adherence at high- and low-performing hospitals. Background:. VTE is the most common preventable cause of death after abdominopelvic cancer surgery, yet adherence to guideline-recommended postdischarge VTE chemoprophylaxis remains suboptimal. A CQIP including audit and feedback of performance data, a toolkit, coaching calls, and best practice alerts was implemented. Methods:. Patients undergoing inpatient abdominopelvic cancer surgery at a CQIP-enrolled hospital during a 3-year study period were included. Unadjusted and adjusted rates were calculated for postdischarge VTE chemoprophylaxis adherence. High performance was defined as >10% improvement and/or ≥80% adherence. We conducted semistructured interviews and focus groups with collaborative members to identify barriers and facilitators to implementation. Results:. Postdischarge VTE chemoprophylaxis adherence increased from 51.8% (preimplementation) to 64.5% (postimplementation; P < 0.05). Patients who underwent urologic (odds ratio [OR], 1.76 [95% CI, 1.27–2.43]) and gynecologic procedures (OR, 3.90 [95% CI, 2.73–5.58]) were more likely prescribed appropriate VTE chemoprophylaxis compared with colorectal procedures. Eight hospitals (50%) had improvement in adherence rates, and 8 (50%) were high performers. Barriers to implementation included a lack of surgeon buy-in, technical challenges, and a lack of awareness. Conclusions:. A CQIP was associated with increased postdischarge VTE adherence rates. Different barriers exist between high- and low-performing hospitals. Future collaborative work should focus on hospital-level interventions to improve low-performer results.

BACKGROUND:For patients with clinical T2N0M0 (cT2N0M0) esophageal squamous cell carcinoma (ESCC), upfront esophagectomy is recommended for low-risk tumors (tumor size less than 3 cm, low-grade histology), and neoadjuvant chemoradiation with esophagectomy or chemoradiation alone is recommended for high-risk tumors (tumor size 3 cm or greater, high-grade histology). The objectives of this study were to (1) describe the treatment strategies used for patients with cT2N0M0 ESCC and (2) analyze survival outcomes for patients according to treatment strategy and tumor risk category. STUDY DESIGN:We performed a retrospective cohort analysis of patients with cT2N0M0 ESCC in the National Cancer Database from 2006 to 2020 comparing patients by tumor risk categories. We compared characteristics of patients according to treatment strategy using bivariate analyses. We performed multivariable Cox regressions comparing overall survival outcomes of patients according to treatment strategy and tumor risk category. RESULTS:Of the included patients, 145 of 890 (16.3%) with cT2N0M0 ESCC underwent esophagectomy, 176 of 890 (19.8%) underwent neoadjuvant chemoradiation with esophagectomy, and 418 of 890 (47.0%) underwent chemoradiation. Among patients with low-risk cT2N0M0 ESCC, 44 of 222 (19.8%) underwent esophagectomy. Among patients with high-risk cT2N0M0 ESCC, 126 of 668 (18.9%) underwent neoadjuvant chemoradiation with esophagectomy and 332 of 668 (49.7%) underwent chemoradiation therapy. Patients with high-risk tumors undergoing chemoradiation had a 53% higher risk of death than patients with high-risk tumors undergoing neoadjuvant chemoradiation with esophagectomy (adjusted hazard ratio 1.53 [1.15 to 2.05]). CONCLUSIONS:Approximately half of patients with cT2N0M0 ESCC received guideline-concordant care. Chemoradiation therapy is overused in patients with high-risk tumors and upfront esophagectomy is underused in patients with low-risk tumors.