Whose risk is it anyway?

Powell et al 1 have proposed the importance of 90-day mortality after lung cancer surgery, and have generated a predictive score using predominantly objective information. There are obvious advantages over the frequently quoted Thoracoscore which contains more subjective assessments of patient performance, and is based on data from a wide range of thoracic procedures including those for benign disease. Their use of 90-day mortality as the outcome measure has merit, but its implications need further consideration. This measure may not reflect the standard of the operation. A lot can happen in that time: the risk of mortality in the first 3 months after surgery may be related to the side effects (direct or indirect) of adjuvant chemotherapy, or from comorbidity, that is, infective exacerbations of chronic obstructive pulmonary disease or even the natural history of the disease. The surgeon can only really influence the inhospital treatment; after discharge, the quality of primary care or medical care received from local referring physicians may also be important. One wonders whether 90-day mortality was arbitrarily chosen for statistical reasons, and it is noted that no surgeon was involved as a coauthor of this paper. The parameter favoured for surgical performance would be inhospital mortality giving the patient an estimate of the chance of going home which must be their immediate priority. When we report the apparent risk of an operation to remove a bronchogenic carcinoma the value is viewed by many parties involved in the interaction between patient and surgeon. This value means different things to different parties and begs the question: ‘whose risk is it anyway?’