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Dorothy Smith, an elderly and somewhat portly woman, presented to her local emergency room with chest pain and shortness of breath. An extensive evaluation revealed no evidence for coronary artery disease, congestive heart failure, or pneumonia. A chest radiograph demonstrated a large air-fluid level posterior to her heart shadow, a finding that all thoracic surgeons recognize as being consistent with a large paraesophageal hiatal hernia. The patient had not had similar symptoms previously. Her discomfort was relieved after a large eructation, and she was discharged from the emergency room a few hours later. When seen several weeks later in an outpatient setting by an experienced surgeon, who reviewed her history and the data from her emergency room visit, she was told that surgery is sometimes necessary to repair such hernias.

Evidenced-based medicine (EMB) is a philosophical approach to clinical problems introduced in the 1980s by a group of clinicians with an interest in clinical epidemiology at McMaster University in Canada. The concepts associated with this approach have been widely disseminated and described by many as a paradigm shift. Others, however, have debated the usefulness of this approach.

Accumulation of new and more reliable information has been monumental over the last decades, mediated via unprecedented growth in biomedical and associated social sciences research. This research has certainly played a key role in the tremendous improvement of health throughout the world. It has also complicated decision making, both at the individual and at the policy level, by presenting clinicians with an increasing number of medical technologies and strategies for the management of a given medical situation. A fundamental concern in clinical decision making is how to synthesize information about the effect of a medical intervention on patients with specific characteristics. Furthermore, an additional critical step involves integrating population level evidence about outcomes with patient-level values for these outcomes in order to produce individualized care.

Examining surgical trends before the National Emphysema Treatment Trial (NETT) demonstrates the importance of nonclinical determinants of care. The number of lung volume reduction surgery (LVRS) claims increased dramatically after 1994 despite the fact that there was considerable uncertainty in the available evidence base. Favorable media reports and testimonials from patient advocacy groups may have influenced both patient and surgeon attitudes about LVRS. Some surgeons felt that investigations prior to the NETT demonstrated clear and dramatic improvements in quality of life, sufficient to justify Medicare reimbursement for the procedure. Accordingly, they believed the NETT was a form of coercion because patients who refused to enroll in the study would not have financial coverage of their LVRS or receive the operation from a NETT surgeon. Furthermore, even if patients enrolled, the study deprived half of them a procedure with “established” benefits.

Recent studies of patient decision making about surgical options that involve making trade-offs between benefits and harms underscore major gaps in decision quality. Following standard counseling, patients’ score D on knowledge tests and F on their understanding of the probabilities of benefits and harms. Moreover, there is a mismatch between the benefits and harms that patients’ value most and the option that is chosen. Patients participate in decision making less than they prefer; some have high levels of decisional discomfort which is an independent predictor of downstream dissatisfaction, regret, and the tendency to blame their doctor for bad outcomes. The underlying mechanisms explaining the poor decision quality with standard counseling is (1) patients’ difficulties recalling facts and understanding probabilities and (2) surgeons’ difficulties judging the values that patients’ place on benefits versus harms.

The issue of how to preoperatively stage patients with known or suspected lung cancer is complex, and remains confusing despite a large number of publications on the subject. Part of the confusion arises from the multiplicity of available tests, but more importantly from the fact that the question to be addressed varies in different patient groups. There are different subgroups of patients, particularly with respect to mediastinal staging. The patients considered in one study may not be the same as those in another study, and often arguments are made for a particular approach in some patients using data that is not applicable because it pertains to a different subgroup. Another major obscuring factor is the frequent difference in perspective of authors and practicing clinicians. In general, papers addressing the value of a procedure have retrospectively included all patients who underwent the procedure, and not defined the characteristics of the patients.

Cervical mediastinoscopy is a widely used procedure in the invasive staging of non-small cell lung cancer (NSCLC). lung cancer (NSCLC). It is a safe invasive diagnostic procedure that has been shown to have a morbidity rate of 1.7%, a mortality rate of 0.07%, and an emergency thoracotomy rate of 0.12%. Most commonly, it is done after noninvasive staging modalities have demonstrated no advanced disease, and is the final step in the determination of the benefit of surgical resection. Mediastinoscopy policies differ among countries, institutions, and surgeons, but generally it is done either selectively or routinely. selectively or routinely. There is a strong consensus for performing this in patients with enlarged mediastinal lymph nodes, but there is less than widespread acceptance for performing it in the setting of normal-sized nodes.

The appropriate therapy for stage IIIa (N2) non-small cell lung cancer (NSCLC) is not clearly established. Recent randomized trials demonstrate that preoperative chemoradiotherapy followed b y resection improves long-term and disease-free survival compared with surgery alone. These results have bolstered the interest in multimodality treatment for patients with resectable N2 disease. Furthermore, the literature suggests that neoadjuvant therapy followed by surgery is superior to resection and subsequent adjuvant treatment, although such a comparison has not been definitively studied. Based on these results, patients who a re found to have N2 nodal metastasis prior to thoracotomy, using methods such as mediastinoscopy, thoracoscopy, endoscopic ultrasonography, transbronchial needle aspiration, or possibly positron emission tomography (PET) scanning, should receive neoadjuvant treatment prior to resection.

Non-small cell lung cancer (NSCLC) remains a leading cause of death and will cause approximately 163,500 deaths in the United States in 2005. While patients presenting with localized disease have the best chance of being cured, they represent a minority of patients and unfortunately have a significant likelihood of developing recurrent disease after treatment and ultimately dying of their disease. The 5-year survival for patients presenting with clinical stage I lung cancer ranges from 38% to 61%; for those with pathological stage IA disease, the survival is 67%.

One of the major goals of the International Staging System for Lung Cancer, first introduced in 1986 and subsequently revised in 1997, was the separation of patients into potentially resectable and unresectable categories. This dividing line was set between stage IIIA and stage IIIB disease with contralateral lymph node metastases or local involvement of unresectable or marginally resectable structures defining the limits of surgical treatment. treatment. The advent of modern cancer therapy with multimodality approaches including surgery, chemotherapy, and radiation therapy has raised significant questions that are still not completely resolved as to the best approach for patients with potentially resectable stage IIIA (N2) disease at presentation.