Quality Improvement

Overall survival rates of esophageal cancer have risen in the past 50-plus years, from 5% in 1970 to 22% in 2023. Yet, no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that incorporate input from surgeons, radiation oncologists, and medical oncologists have been available, until now. 

The Society of Thoracic Surgeons, American Society for Radiation Oncology, and American Society of Clinical Oncology have co-authored the first comprehensive guideline on the management of esophageal cancer. Published today in The Annals of Thoracic Surgery, the guideline addresses key clinical subject areas pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer. 

The guideline delivers recommendations for the use of induction chemotherapy, optimal radiation dose, value and timing of esophagectomy, use of chemotherapy vs. chemoradiotherapy before surgery, approach and extent of lymphadenectomy, and the value of adjuvant therapy after resection.

“These comprehensive guidelines address areas critical for standardizing and improving care and outcomes for esophageal cancer patients,” says study investigator Stephanie Worrell, MD, clinical associate professor and thoracic section chief at the University of Arizona in Tucson. “The recommendations are based on a comprehensive review of innovations and advancements in the most recent literature.”

For the first time, The Society of Thoracic Surgeons joined the Korean Society for Thoracic and Cardiovascular Surgery (KSTCVS) in their presentation of the Heart Valve Disease Forum (HVDF), an annual conference that delivers the latest developments on the basis, cause, diagnosis, treatment, and future of valve disease.

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The forum, held September 15-16, 2023, in Dragon City, Yongsan, Seoul, was led by the President of the HVDF, Dr. Kyung Hwan Kim, and organized by co-program directors Dr. Joon Bum Kim of Asan Medical Center of Ulsan College of Medicine and Dr. S. Chris Malaisrie of Northwestern University, who commented “STS was thrilled to partner with the KSTCVS on this international event, highlighting transpacific expertise on valves.”

Dr. Kim remarked, “By co-hosting the forum with STS, we brought together the world’s top scholars in related fields for discussion and achieved the best conference experience.”

More than 300 surgeons, residents, and other medical students attending the conference heard from luminary surgeons and professors on today’s hottest topics impacting the specialty, including TAVI, innovative SAVR, and endocarditis, and trained on surgical techniques in wet labs. “The dynamic, case-based discussions and interactive wet labs with skilled faculty inspired the next generation of cardiac surgeons," said Dr. Malaisrie.

Dr. Thomas MacGillivray, president of STS, delivered several talks, including one on “Crisis Management in the Operating Room and Surgeon Leadership.”

At this year’s conference, particular emphasis was placed on connecting young surgeons responsible for the future of heart valve surgery with proven STS surgeon leaders through a mentor-mentee program. It was an exclusive opportunity for early career attendees to gain invaluable guidance on navigating their career paths and overcoming challenges from leaders.

“The heart valve symposium was a wonderful success and a historical event that stands out among the meeting’s 30-year history,” said Dr. Kim. “Our Korean colleagues agreed that collaborating with STS was the best thing in terms of excellence of lectures, one-to-one teaching in the wet lab, an exciting mentorship program, and beautiful times spent outside of the conference room.”

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Since its origins as a task force in 2017, the 16-member STS Workforce on Diversity, Equity, and Inclusion (DEI) has been prolific in creating evidence-based, perspective-changing forums that illuminate disparities in underserved populations of both patients and surgeons—and they recognize that “awareness” was only the first step. 

“When this workforce started as a task force, the original goal was to gauge the equity, diversity and inclusion of STS at that time, and we assessed that with a survey of membership,” said Africa F. Wallace, MD, director of thoracic surgery at Capital Health Surgical Group in Pennington, New Jersey. 

What they found in 2017 was a lack of diversity in STS leadership. This has since prompted changes to STS recommendations for nominating and selecting its leaders, specifically encouraging members from underrepresented groups to self-nominate, inviting leadership recommendations from diverse stakeholders, and encouraging STS Board members, council chairs, and workforce chairs to recommend residents, women, and underrepresented minorities for leadership positions. 

"Our roles as attendings, division chiefs, chairs, coaches, and mentors come with a larger responsibility. If we are to change what medicine looks like and our interactions with patients, at some point we have to take a stand.” 

- Africa F. Wallace, MD

The Workforce has been tireless in challenging the barriers that can confound a career for an aspiring cardiothoracic surgeon who is part of an underrepresented community—not only in access to education and resources but in the nuances of day-to-day interactions related to training, jobseeking, pay equity, mentorship opportunities, and team dynamics.  

For example, in a free-access article published last month in The Annals of Thoracic Surgery, STS DEI Workforce members engaged in an open dialogue with members of the STS Workforce on Patient Safety, centered around a case scenario in which a patient makes racist and sexist remarks toward a general surgery resident working with a heart team. 

The discussion centered around how a patient’s bias can pose a real safety threat. In a specialty where every member of the team is critical, changing up routines to suit that bias could compromise the quality of care that patient receives.  

During the exchange, Dr. Wallace identified the scenario as an opportunity for surgical team leaders to stand up for their colleagues, creating an environment where an aspiring surgeon feels supported. 

When a surgeon delivers excellent care in the face of prejudice, it’s a pivotal way to reach patients who have a biased mindset, Dr. Wallace acknowledged. But that’s not adequate to create a setting that’s welcoming to diverse surgeons.  

“As the leader, you have a responsibility to protect those who are working with you and set an example for them,” Dr. Wallace emphasized. “Our roles as attendings, division chiefs, chairs, coaches, and mentors come with a larger responsibility. If we are to change what medicine looks like and our interactions with patients, at some point we have to take a stand.” 

The article is just the first of a series of case-based discussions among the two workforces on how racism—on the part of providers and patients—affects patient care. And it’s one of dozens published recently in The Annals with the goal of promoting real change in the DEI arena. The Workforce also has created numerous webinars, Database analyses, three seasons of the “Same Surgeon, Different Light” podcast, and other top-quality resources—as well as an extraordinary array of presentations at the STS Annual Meeting—with the aim of cultivating a more diverse environment for cardiothoracic surgery. 

“We have gone from documenting disparities to highlighting speakers who are actually implementing activities and research and efforts to eliminate disparities,” said Workforce chair David Tom Cooke, MD, professor and founding chief of general thoracic surgery at UC Davis Healthcare in Sacramento. “Not just saying that disparities exist, but that these are our action items to eliminate them.”   

As a workforce and as individuals, the members have educated Congressional leaders and their staffs on the purpose of risk calculators as essential tools for assisting surgeons in making the best choices for patient care and postoperative support. They also advocate for diverse patient representation in studies that inform the calculators, as well as the integration of socioeconomic variables, to demonstrate the reality that different outcomes among races and genders aren’t simply biological. 

As for cardiothoracic surgeons as a community, “The willingness to achieve diversity is not counter to meritocracy,” Dr. Cooke said, “and the data support that. We are not seeking platitudes; we are seeking action and true empathy—with tangible progress.” 

Find an extensive catalog of the Workforce’s achievements and initiatives at sts.org/diversity.  

For patients with multivessel coronary artery disease, contemporary data analyses demonstrate that the optimal treatment is coronary artery bypass grafting (CABG), and that new downgraded recommendations for CABG could put patients at risk. 

During the STS 59th Annual Meeting in January, researchers presented compelling findings, comparing outcomes for patients who underwent CABG versus those who opted for percutaneous coronary intervention (PCI).   

“The findings of our study were very convincing,” said J. Hunter Mehaffey, MD, MSc, from the Department of Cardiovascular and Thoracic Surgery at West Virginia University. His team’s presentation, “Contemporary Artery Bypass Grafting versus Multivessel Percutaneous Coronary Intervention in 100,000 Matched Medicare Beneficiaries,” revealed that patients with blockages in multiple arteries who opt for CABG—rather than for PCI—are less likely to die from their condition, less likely to need additional surgery, and less likely to have a subsequent heart attack. 

“The singular message to the public is that the optimal treatment for multivessel coronary artery disease—to improve not only long-term survival but also lower your risk of complications—is coronary artery bypass surgery.”

- J. Hunter Mehaffey, MD 

The background and rationale for this research project started with the publication of the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. “The cardiac surgery world was really shocked, because the guidelines downgraded the indications for CABG from a class 1 recommendation to a class 2B,” Dr. Mehaffey explained.  

Much of the decision to downgrade was based on the guideline committee’s goals to focus on the most recent data, to help ensure that they were capturing contemporary stent technology, Dr. Mehaffey explained. The guidelines therefore relied heavily on the multicenter ISCHEMIA trial, published by Maron et al in 2020. 

“ISCHEMIA wasn’t a study that was designed to look at CABG versus medical therapy in terms of survival,” said Joseph F. Sabik III, MD, chair of the Department of Surgery at UH Cleveland Medical Center in Ohio. “It was really a study that was done to look at initial conservative strategy versus an initial invasive strategy.”  

Dr. Mehaffey’s multidisciplinary team—including both surgeons and cardiologists—performed a statistical analysis of Medicare outcomes data in patients 65 and older from 2018 to 2020, including propensity score balancing to help ensure that the groups of patients who underwent stenting versus those who underwent bypass surgery were well matched in order to compare their outcomes. 

The analysis demonstrated a significantly lower hospital mortality for the patients who underwent CABG compared to those who underwent PCI. Additionally, the researchers found a marked reduction in both 30-day and 3-year readmissions for myocardial infarction. CABG patients were also significantly less likely to need any additional stenting or intervention on their coronary arteries during those 3 years, and—most significantly—those who underwent CABG had a nearly 60% reduction in death at 3 years compared to those who had PCI. 

“The singular message to the public is that the optimal treatment for multivessel coronary artery disease—to improve not only long-term survival but also lower your risk of complications—is coronary artery bypass surgery,” Dr. Mehaffey said.  

Meanwhile, Dr. Sabik’s team analyzed the past 2 years’ outcomes in the STS National Database™, which captures nearly every adult cardiac surgical procedure in the United States. “We wanted to examine how representative ISCHEMIA is for patients undergoing surgery, to see if the results are applicable,” Dr. Sabik said. 

They discovered that, based on the eligibility criteria for the ISCHEMIA trial, only about one-third of patients who underwent CABG would have been included in the study. A third would have been excluded because they had left main disease, and the other third would have met other exclusion criteria. 

“ISCHEMIA wasn’t a study that was designed to look at CABG versus medical therapy in terms of survival. It was really a study that was done to look at initial conservative strategy versus an initial invasive strategy.”  

- Joseph F. Sabik III, MD

Compared with that of the STS population, it turned out that patients who met ISCHEMIA criteria tended to have less severe disease. They didn’t have the same extent of coronary artery blockage or comorbid conditions. They tended to be younger, and they were less likely to have hypertension, diabetes, a previous stroke, peripheral vascular disease, or renal dysfunction, Dr. Sabik said. ISCHEMIA participants also were less likely to have had a myocardial infarction and more likely to have better left ventricular function. 

“Though the authors of ISCHEMIA did their best to represent patients undergoing revascularization, the study wasn’t truly representative of patients with triple-vessel disease having surgery today,” concluded Dr. Sabik. “That’s why we don’t think it should have been used to downgrade coronary surgery recommendations. People are making decisions based on these guidelines, and it may not be in the best interest of patients.” 

“This is not about surgery. It’s not about PCI, it’s not about medical therapy. It’s about making sure that patients get the right treatment, so they can have the best long-term outcomes.” 

- Joseph F. Sabik III, MD

During the 2023 C. Walton Lillehei Lecture, Peter K. Smith, MD, outlined a series of narratives that can cloud a provider’s decision-making when choosing their approach to coronary artery disease. He illuminated the nuances of commonly cited trials such as SYNTAX and FAME, detailed the evolution of common percutaneous approaches, and explained how belief in the advantages of PCI becomes murkier when the arguments aren’t equivalent. 

"There was exhaustive discussion of the age of the ‘CABG versus medical therapy’ evidence,” Dr. Smith said. “And then we entered the spin zone of indirect comparisons of ‘CABG versus medical therapy, CABG versus Stent X, Stent X versus Stent Y, Stent Y versus medical therapy—therefore CABG versus medical therapy.’ And, of course, ‘Those were all old stents and medical therapy is markedly improved now.’ This is what occurs when a core belief system is at risk.” 

“We need to work at a local level with cardiology, with heart teams, in order to make the right decisions for patients,” urged Dr. Smith. 

“This is not about surgery,” added Dr. Sabik. “It’s not about PCI, it’s not about medical therapy. It’s about making sure that patients get the right treatment, so they can have the best long-term outcomes.” 

STS 2023 registrants can watch Dr. Mehaffey’s presentation, Dr. Smith’s Lillehei Lecture, and Dr. Sabik’s late-breaking session, “The ISCHEMIA Trial Does Not Reflect Patients Undergoing Coronary Surgery: An STS Cardiac Surgery Database Analysis,” as part of their free Annual Meeting Online access. Those who didn’t register can purchase Annual Meeting Online—with special discounts for STS Members—and Resident/Fellow Members can access it for free. Visit sts.org/AMonline.