Abstract
Background: Lobar resection is the gold standard therapy for medically fit patients with stage I non-small cell lung cancer (NSCLC). However, considerable variability exists in the use of surgical therapy. This study tested the hypothesis that center-based variation in the use of surgical therapy affects survival in NSCLC. Methods: We queried the National Cancer Database for patients with stage I NSCLC. Mixed-effects multivariable models were developed to establish the per-center adjusted rate of surgical therapy. Patients were stratified into quartiles based on the treating center's adjusted rate of surgical therapy. Survival was estimated and then tested by using Kaplan-Meier and the log-rank test. Multivariable Cox proportional hazard models were developed to estimate the effect of rate of surgical therapy on overall survival. Results: A total of 139,802 patients met the criteria. There was wide variation in the per-center rate of surgical resection in the highest (80.8%) versus lowest (41.4%, p < 0.001) quartile. Across cohorts, patients were similar in age (mean 68.8 years in the highest quartile versus 69.7 in the lowest quartile) and Charlson-Deyo Score of 2 or greater (15.1% in the highest quartile versus 14.4% in the lowest quartile). Five-year survival was higher for patients treated at high-use centers (52.7% versus 36.7%, p < 0.001). After adjustment, an adjusted rate of surgical therapy in the lowest 25th percentile was associated with lower survival (adjusted hazard ratio 1.40, 95% confidence interval: 1.37 to 1.40, p < 0.001). Conclusions: Treatment at a center with a higher rate of surgical therapy confers a considerable survival advantage, even after adjustment for hospital volume, surgical approach, and other confounders. Targeted efforts to improve adherence to guidelines about provision of surgical therapy in early-stage NSCLC may represent a meaningful opportunity to improve outcomes.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1533-1540 |
| Number of pages | 8 |
| Journal | Annals of Thoracic Surgery |
| Volume | 106 |
| Issue number | 5 |
| DOIs | |
| State | Published - Nov 2018 |
| Externally published | Yes |
Bibliographical note
Funding Information:This work was supported by the National Institutes of Health (NIH)-funded Cardiothoracic Surgery Trials Network grant 5U01HL088953-05 (B.A.Y.) and the NIH TL-1 Clinical and Translational Science Award (CTSA) 1UL1-TR001117-01 (National Center for Advancing Translational Sciences; NCATS). The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used or the conclusions drawn from these data by the investigator.
Funding Information:
This work was supported by the National Institutes of Health (NIH)-funded Cardiothoracic Surgery Trials Network grant 5U01HL088953-05 (B.A.Y.) and the NIH TL-1 Clinical and Translational Science Award (CTSA) 1UL1-TR001117-01 ( National Center for Advancing Translational Sciences ; NCATS). The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used or the conclusions drawn from these data by the investigator.
Publisher Copyright:
© 2018 The Society of Thoracic Surgeons
