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Two papers recently published in The Annals of Thoracic Surgery aim to guide the management of thymoma¹ and pleural drains following pulmonary lobectomy² – thoracic conditions and treatments that lack widely accepted guidelines. Recognizing this need, the Society of Thoracic Surgeons (STS) Workforce on Evidenced-Based Surgery convened a task force to develop expert consensus documents to help alleviate this knowledge gap.

Thymoma, a rare epithelial tumor – but also the most common anterior mediastinal tumor in adult patients – is a condition thoracic surgeons will likely encounter as clinicians. However, there is a lack of evidence covering all aspects of treatment due to its relatively low incidence. Managing pleural drains following pulmonary lobectomy is standard practice, yet there are no established guidelines on this topic despite abundant published literature.

Management of thymoma

The STS Workforce on Evidence-Based Surgery, which includes general thoracic surgeons with expertise in thoracic surgical oncology, and medical and radiation oncologists with expertise in neoadjuvant and adjuvant therapies, evaluated existing literature about surgical considerations in managing thymomas, such as:

•    Imaging characteristics
•    Diagnostic tests 
•    Staging 
•    Surgical approach and technique
•    Neoadjuvant and adjuvant therapy 
•    Surgery for advanced or recurrent disease, and 
•    Postoperative surveillance

Consensus statements were drafted using the modified Delphi method. Votes for each proposed statement were tallied using a 5-point Likert scale, with the option to abstain on those not within the specific authors’ expertise. Statements with 75% of responding authors selecting “agree” or “strongly agree” were considered to have reached a consensus. 

Unlike broader guidelines encompassing various aspects of thymoma management, including medical oncology, radiology, and pathology, this paper addresses thymoma from a surgical perspective by guiding surgical interventions, especially in metastatic and recurrent diseases.

"Given the scarcity of randomized controlled trials due to the rarity of thymoma, this document is framed as an expert consensus rather than strict evidence-based clinical practice guidelines," said the study's lead author, Dr. Douglas Liou, clinical associate professor at Stanford Medicine. "Our findings rely more heavily on the combined experience and judgment of experts in the field rather than solely on data from large-scale studies." 

Read the Annals article. 

Management of pleural drains following pulmonary lobectomy

Similarly, the consensus document developed by the STS Workforce on Evidence-Based Surgery to manage pleural drains includes:

•    Choice of drain, including size, type, and number
•    Management, such as use of suction versus waterseal and criteria for removal
•    Imaging recommendations, including the use of daily and post-pull chest x-rays
•    Use of digital drainage systems, and
•    Management of prolonged air leak

Workforce members reviewed existing literature on the condition. A consensus using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached, with a total of thirteen statements that encouraged standardization and stimulated additional research in this critical area. 

“Optimal management of these drains should reduce patient discomfort, length of stay, and complications.”  said study investigator Dr. Michael Kent, associate professor of surgery at Harvard Medical School. “However, despite how commonly chest tubes are used in practice, the literature must provide more clarity on this subject. Many important questions have yet to be addressed and may require well-designed, prospective randomized trials.”

Read the Annals article. 

1. Reference: Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas, The Annals of Thoracic Surgery (2024)

2. Reference: Kent MS, Mitzman B, Diaz-Gutierrez, I, Khullar OV, Fernando H, Backus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Worrell SG, Raymond DP, Schumacher L, Hayanaga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy, The Annals of Thoracic Surgery (2024)

This afternoon the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 Medicare Physician Fee Schedule Proposed Rule. STS has compiled a summary of key provisions affecting thoracic surgery in the rule. 

Payment Cuts

CMS is again proposing significant cuts to cardiothoracic surgery reimbursement, this time by 2.8%. CMS estimates the CY 2025 conversion factor (CF) to be $32.36. Unlike hospital payments with a built-in yearly increase, physician payments do not have such adjustments. STS will continue lobbying Congress and CMS for systematic reforms and an inflationary update to Medicare payments.

Changes to physician reimbursement often stem from the budget neutrality requirement, which lacks a mechanism for inflationary adjustments. Disruptions occur when the value of specific services change, affecting the reimbursement of other services to maintain budget neutrality. STS and the physician community are advocating for Congress to legislate an inflationary update to the CF and adjust budget neutrality thresholds. For more details, see our recent response to the Senate Finance Committee’s request for information on physician payment. 

Quality Payment Program (QPP)

Thanks to advocacy efforts from STS and other stakeholders, Congress has stepped in to extend a 3.5% incentive payment for Advanced Alternative Payment Model (APM) participation in CY 2025 (based on CY 2023 participation). Additionally, starting in payment year 2026, APM participants will be eligible for a higher CF update than other clinicians: 0.75% compared to 0.25%. 

STS previously worked with CMS to provide specialty-specific, meaningful measures for our members who participate in the Bundled Payments for Care Improvement (BPCI) Advanced APM. Additionally, this will be relevant for CT surgeons performing CABG procedures under the new TEAM payment model proposed in the inpatient payment rule. CMS is considering, with STS support, allowing TEAM participation to count towards Advanced APM participation under the QPP.

Global Surgical Codes 

CMS is proposing to expand the use of transfer of care modifiers for global packages. They would require the use of modifiers (-54, -55, and -56) for all 90-day global surgical packages in cases where a practitioner (or another from the same group) expects to provide only the pre-operative (-56), procedure (-54), or post-operative (-55) portions. This applies to both formally documented and informally expected transfers of care. CMS aims to use the information collected to refine global surgical codes in the future.  

In the past, STS has actively promoted the benefits of maintaining the 90-day global code and has refuted flawed data used to advocate for their repeal. We will continue to promote the value of these bundled payments and urge policymakers to extend the increased reimbursement for E/M visits to those packaged in procedural global payments.  

Telehealth

CMS has extended telehealth flexibilities where possible, including adding new services to the telehealth list and permitting two-way and real-time audio-only communication technology for any telehealth service. Absent congressional intervention, the future of telemedicine hangs in the balance as the current telehealth flexibilities are scheduled to expire on December 31, 2024. STS urges Congress to permanently extend telehealth flexibilities established during the COVID-19 public health emergency. 

*Please note, this article was updated on September 5, 2024:

*After STS submitted letters to the Centers for Medicare & Medicaid Services  and the United States Preventive Services Task Force, the Centers for Medicare & Medicaid Services (CMS) responded, stating they cannot reconsider the National Coverage Determination (NCD) at this time. Following this, STS, the GO2 Foundation for Lung Cancer, and the American College of Radiology (ACR) met with CMS and had a productive conversation about the steps that need to occur, and the data needed to reconsider the NCD. USPSTF has also responded, indicating that this issue will be considered at their Topic Prioritization Workshop in the fall.

On June 21, 2024, The Society of Thoracic Surgeons, The American College of Radiology®, and the GO2 Foundation for Lung Cancer submitted joint letters to the Centers for Medicare & Medicaid Services and the US Preventive Services Taskforce that include recommendations to improve existing lung cancer screening eligibility requirements. 

The organizations formally requested reconsideration of the National Coverage Determination (NCD) for screening lung cancer with low-dose computed tomography and asked to eliminate the exclusion criteria of current smokers or people who have quit smoking within the last 15 years and the upper age limit. This would align the NCD with the updated American Cancer Society and the National Comprehensive Care Network evidence-based guidelines. 

Removing these criteria would significantly increase the number of high-risk individuals eligible for screening from 14.2 million to 19.2 million. Annual lung cancer screening with low-dose computed tomography in high-risk patients significantly reduces lung cancer deaths and may help identify cancers at an early, treatable, and curable stage.  

If you have questions about STS’s lung cancer screening advocacy efforts, contact Haley Brown, senior manager, political affairs and advocacy.