Outcomes With Lobectomy, Sublobar Resection, and Stereotactic Ablative Radiotherapy in Medicare Patients With Early-Stage NSCLC
In a study on use of the most common definitive therapies for non–small cell lung cancer (NSCLC) in Medicare patients reported in JAMA Surgery, Shirvani et al found that lobectomy was associated with improved outcome vs sublobar resection and that stereotactic ablative radiotherapy may be of particular benefit in very old patients with multiple comorbidities. The incidence of early-stage NSCLC in the elderly is expected to increase due to aging of the population and increased use of computed tomographic screening.
Study Details
The study involved Surveillance, Epidemiology, and End Results (SEER)-Medicare data on 9,093 patients with early-stage node-negative NSCLC who underwent treatment with lobectomy (79.3%), sublobar resection (16.5%), or stereotactic ablative radiotherapy (4.2%) between January 2003 and December 2009. Overall survival and lung cancer–specific survival were assessed using Medicare claims through December 2012.
Patients had a median age of 75 years, and 54% were female. Pathologic node-negative status was identified by mediastinal sampling in 94.4% of the lobectomy group, 45.2% of the sublobar resection group, and 5.2% of the stereotactic ablative radiotherapy group. Surgical patients were younger and had fewer comorbidities than stereotactic ablative radiotherapy patients.
Unadjusted 90-day mortality was 4.0% with lobectomy, 3.7% with sublobar resection (P = .79 vs lobectomy), and 1.3% with stereotactic ablative radiotherapy (P = .008 vs lobectomy). Unadjusted 3-year mortality was 25.0% with lobectomy, 35.3% with sublobar resection (P < .001), and 45.1% with stereotactic ablative radiotherapy (P < .001).
Multivariate Analysis
Multivariate proportional hazards regression showed that increased age, male sex, increased comorbidity, use of oxygen, use of medical assistance devices, larger tumors, and lower education level, but not race or income level, were associated with poorer survival. Use of mediastinal sampling for staging was associated with improved survival.
Compared with lobectomy, sublobar resection was associated with significantly worse overall survival (adjusted hazard ratio [AHR] = 1.32, P < .001) and lung cancer–specific survival (AHR = 1.50, P < .001). Compared with lobectomy, stereotactic ablative radiotherapy was associated with improved overall survival when performed within 6 months of diagnosis (AHR = 0.45, P < .001) but not when performed thereafter (AHR = 1.66, P < .001). Overall, stereotactic ablative radiotherapy was associated with poorer lung cancer-specific survival (AHR = 1.44, P = .03).
Propensity Score–Matching Analysis
Propensity score–matching analysis (main analysis, 1,077 matched pairs) showed similar findings for sublobar resection vs lobectomy in overall survival (AHR = 1.36, P < .001) and lung cancer–specific survival (AHR = 1.46, P = .004). Propensity score–matching analysis (main analysis, 251 matched pairs) showed no significant difference for stereotactic ablative radiotherapy vs lobectomy in overall survival (AHR = 1.01, P = .94) or cancer-specific survival (AHR = 1.00, P = .99) in cohorts characterized by very advanced age, greater comorbidity, increased oxygen use, and low likelihood of mediastinal sampling.
The investigators concluded: “Our analysis of patients with early-stage NSCLC in the contemporary period supports lobectomy as the optimal treatment for older adults able to undergo surgery. Our findings regarding the comparative effectiveness of [stereotactic ablative radiotherapy] in frail patients with very advanced age are also promising because this technology appears to offer a lower risk for periprocedural mortality and encouraging long-term survival.”
Benjamin D. Smith, MD, of The University of Texas MD Anderson Cancer Center, is the corresponding author for the JAMA Surgery article.
The study was supported by grants from the Cancer Prevention & Research Institute of Texas and National Cancer Institute. For full disclosures of the study authors, visit archsurg.jamanetwork.com.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
