Wildfire Exposure Confers Longer Length of Stay Following NSCLC Surgery

"Future studies should evaluate whether extended hospital stay improves surgical care outcomes during disasters," according to study author Leticia Nogueira, PhD, MPH.

Patients who received curative-intent surgery for non–small cell lung cancer (NSCLC) at facilities impacted by a wildfire disaster experienced longer length of stay (LOS) vs similar patients who underwent treatment at times when no disasters occurred, according to findings published in the Journal of the National Cancer Institute.¹

Among all patients, the LOS was 7.45 days (SE, 0.22) for patients treated at facilities without wildfire exposure vs 9.42 days (SE, 0.25) among patients who received surgery at facilities exposed to wildfires (P <.0001). In each respective wildfire exposure group, the LOS was 7.45 days (SE, 0.28) vs 9.52 days (SE, 0.33) for those with stage I disease (P <.0001), 8.08 days (SE, 0.51) vs 9.49 days (SE, 0.53) for patients with stage II disease (P = .01), and 6.78 days (SE, 0.51) vs 9.79 days (SE, 0.70) for those with stage III disease (P = .0009).

Zip code level median income (P = .78) and comorbidity burden (P = .96) did not impact the association between wildfire disaster exposure at the treating facility’s county and LOS after lung cancer surgery. Additionally, sensitivity analysis showed no differences regarding in-hospital mortality for patients with exposure to wildfires (10.5%) vs those without exposure (10.8%; P = .76). Main results did not change when investigators excluded data related to patients who were not discharged from the hospital alive or those who underwent surgery following the beginning of the COVID-19 pandemic.

“These data are critical as there are currently no guidelines for protecting the health and safety of patients recovering from lung cancer surgery during wildfires in the United States. In the absence of guidelines, clinicians might resort to improvisational strategies, such as extending post-operative [LOS] to support surgical recovery and better protect the health and safety of patients during wildfires,” lead study author Leticia Nogueira, PhD, MPH, scientific director of Health Services Research at the American Cancer Society, stated in a press release on these findings.² “Future studies should evaluate whether extended hospital stay improves surgical care outcomes during disasters. Also, these findings should be considered for disaster preparedness guidelines tailored to vulnerable patient populations and contextual adjustments to quality care metrics.”

Investigators collected information from the National Cancer Database related to patients 18 years and older who underwent curative-intent lobectomy or pneumonectomy for stage I to III NSCLC from 2004 to 2021. The study defined exposure as a Federal Emergency Management Agency (FEMA) wildfire Presidential Disaster Declaration in the treatment facility’s county from the time of surgery to the time the patient is discharged from the hospital.

The study’s main end point was LOS, which investigators defined as the days between the period of surgery and time of discharge, death, or study end. Additionally, sensitivity analyses implemented propensity-score matching and LOS calculations to exclude patients with in-hospital mortality or surgery following the onset of the COVID-19 pandemic.

Investigators matched patients with wildfire exposure 1:1 to those who received surgery at the same facility during times when no disasters were declared. Ensuring comparability between patients with and without exposure based on demographic and clinical characteristics involved the use of propensity-score matching.

Among 1070 patients who were included in the study, the median age was 69.3 years. Most patients were female (52.7%), non-Hispanic White (77.8%), and had stage I disease (62.8%). In patients with and without exposure to wildfires, respectively, most had lobectomy (93.5% vs 93.8%), open surgery (72.9% vs 76.3%), insurance with Medicare (60.7% vs 60.4%), treatment at a comprehensive facility (38.7% vs 38.7%), no comorbidities (68.0% vs 64.3%), and a zip code level median income of at least $63,000 (40.7% vs 40.0%).

“This study is just the tip of the iceberg showing how extreme weather may be impacting patients with chronic illnesses,” study author Amruta Nori-Sarma PhD, deputy director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health, said in the press release.² “As the wildfire season gets longer and more intense, and wildfires start affecting broader swathes of the US population, health care providers need to be ready with updated guidance that best protects their patients’ health.”

References

1. Nogueira LM, Yabroff KR, Yates E, Shultz JM, Valdez RB, Nori-Sarma A. Facility exposure to wildfire disasters and hospital length of stay following lung cancer surgery. JNCI. Published online March 11, 2025. doi:10.1093/jnci/djaf040
2. New ACS led study finds wildfires pose challenges to cancer care. News release. American Cancer Society. March 11, 2025. Accessed March 12, 2025. https://tinyurl.com/23vshekc