Lobectomy remains the cornerstone of care for stage I NSCLC while sublobar resection and stereotactic body radiation therapy (SBRT) are reserved for patients with smaller tumors and/or poor operative risk. Herein, we investigate the effect of patient frailty on treatment modality for stage I NSCLC at a safety-net hospital.
Patients and Methods
A retrospective chart review was performed of stage I NSCLC patients between 2006 and 2015. Demographics, patient characteristics, and treatment rates were compared to a National Cancer Database cohort of stage 1 NSCLC patients. Patient frailty was assessed using the MSK-FI.
In our cohort of 304 patients, significantly fewer patient were treated via lobectomy compared to national rates (P < .001). Advanced age (P = .02), lower FEV1 (P < .001) and DLCO (P < .001), not socioeconomic factors, were associated with higher utilization of non-lobectomy (sublobar resection or SBRT). Patients with lower MSK-FI were more likely to receive any surgical treatment (P = .01) and lobectomy (P = .03). Lower MSK-FI was an independent predictor for use of lobectomy over other modalities (OR 0.75, P = .04). MSK-FI (OR 0.64, P = .02), and FEV1 (OR 1.03, P < .001) were independently associated with use of SBRT over any surgery.
Our safety-net hospital performed fewer lobectomies and lung resections compared to national rates. Patient frailty and clinical factors were associated with use of SBRT or sublobar resection suggesting that the increased illness burden of a safety-net population may drive the lower use of lobectomy. The MSK-FI may help physicians stratify patient risk to guide stage I NSCLC management.
Abbreviations:NSCLC (Non-small cell lung cancer), MSK-FI (Memorial Sloan Kettering frailty index), SBRT (Stereotactic body radiation therapy), FEV1 (Forced Expiratory Volume in 1 second), DLCO (Diffusion lung capacity for carbon monoxide)
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- Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer.Ann Thorac Surg. 1995; 60: 615-623https://doi.org/10.1016/0003-4975(95)00537-u
- Lobectomy versus stereotactic body radiotherapy in healthy patients with stage I lung cancer.J Thorac Cardiovasc Surg. 2016; 152https://doi.org/10.1016/j.jtcvs.2016.03.060
- Stereotactic body radiation therapy versus surgical resection for stage I non–small cell lung cancer.J Thorac Cardiovasc Surg. 2010; 140: 377-386https://doi.org/10.1016/j.jtcvs.2009.12.054
- Predictors of mortality after surgical management of lung cancer in the national cancer database.Ann Thorac Surg. 2014; 98: 1953-1960https://doi.org/10.1016/j.athoracsur.2014.07.007
- Stage I non-small-cell lung cancer: long-term results of lobectomy versus sublobar resection from the polish national lung cancer registry†.Eur J Cardiothorac Surg. 2017; 52: 363-369https://doi.org/10.1093/ejcts/ezx092
- Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a Multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial.Lancet North Am Ed. 2022; 399: 1607-1617https://doi.org/10.1016/s0140-6736(21)02333-3
- Pl03.06 lobar or sub-lobar resection for peripheral clinical stage IA = 2 cm non-small cell lung cancer (NSCLC): results from an international randomized phase III trial (CALGB 140503 [alliance]).J Thorac Oncol. 2022; 17https://doi.org/10.1016/j.jtho.2022.07.012
NCCN clinical practice guidelines in oncology (NCCN Guidelines). Version 7. 2019.
- Survival and treatment of non-small cell lung cancer stage I–II treated surgically or with stereotactic body radiotherapy: patient and tumor-specific factors affect the prognosis.Ann Surg Oncol. 2014; 22: 316-323https://doi.org/10.1245/s10434-014-3860-x
- Validation of a prognostic model to predict survival after non-small-cell lung cancer surgery.Eur J Cardiothorac Surg. 2010; 38: 615-619https://doi.org/10.1016/j.ejcts.2010.03.028
- Long-term survival after non–small cell lung cancer surgery: development and validation of a prognostic model with a preoperative and postoperative mode.J Thorac Cardiovasc Surg. 2006; 132: 491-498https://doi.org/10.1016/j.jtcvs.2006.04.010
- Racial differences in the treatment of early-stage lung cancer.N Engl J Med. 1999; 341: 1198-1205
- Underuse of surgical resection for localized, non-small cell lung cancer among whites and African Americans in South Carolina.Ann Thorac Surg. 2008; 86 (discussion 227): 220-226
- Racial disparities and survival for nonsmall-cell lung cancer in a large cohort of black and white elderly patients.Cancer. 2009; 115: 4807-4818
- Influence of sociodemographic factors on treatment decisions in non–small-cell lung cancer.Clin Lung Cancer. 2020; 21https://doi.org/10.1016/j.cllc.2019.08.005
- Population variations in the initial treatment of non–small-cell lung cancer.J Clin Oncol. 2004; 22: 3261-3268https://doi.org/10.1200/jco.2004.02.051
- Factors associated with treatment of clinical stage I non–small-cell lung cancer: a population-based analysis.Clin Lung Cancer. 2018; 19https://doi.org/10.1016/j.cllc.2018.05.009
- Impact of insurance status on receipt of definitive surgical therapy and posttreatment outcomes in early stage lung cancer.Surgery. 2018; 164: 1287-1293https://doi.org/10.1016/j.surg.2018.07.020
- Safety-net burden hospitals and likelihood of curative-intent surgery for non-small cell lung cancer.J Am Coll Surg. 2011; 213: 633-643https://doi.org/10.1016/j.jamcollsurg.2011.07.014
- Modified frailty index as a predictor of overall and other cause-specific survival in early-stage non-small cell lung cancer patients treated with stereotactic body radiation therapy.Int J Radiat Oncol*Biol*Phys. 2016; 96https://doi.org/10.1016/j.ijrobp.2016.06.1760
- Use of frailty to predict survival in elderly patients with early stage non-small-cell lung cancer treated with stereotactic body radiation therapy.J Geriatr Oncol. 2018; 9: 130-137https://doi.org/10.1016/j.jgo.2017.09.002
- Comparing outcomes of patients with early-stage non–small-cell lung cancer treated with stereotactic body radiotherapy based on frailty status.Clin Lung Cancer. 2018; 19https://doi.org/10.1016/j.cllc.2018.05.008
- Development and evaluation of a new frailty index for older surgical patients with cancer.JAMA Network Open. 2019; 2https://doi.org/10.1001/jamanetworkopen.2019.3545
- 18F-FDG PET for mediastinal staging of lung cancer: which SUV threshold makes sense?.J Nucl Med. 2007; 48: 1761-1766https://doi.org/10.2967/jnumed.107.044362
- Ratio of lymph node to primary tumor SUV on PET/CT accurately predicts nodal malignancy in non–small-cell lung cancer.Clin Lung Cancer. 2015; 16https://doi.org/10.1016/j.cllc.2015.06.001
- Treatment outcomes in stage I lung cancer: a comparison of surgery and stereotactic body radiation therapy.J Thorac Oncol. 2015; 10: 1776-1784https://doi.org/10.1097/JTO.0000000000000680
- Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function.Ann Surg. 2012; 256: 487-493https://doi.org/10.1097/sla.0b013e318265819c
- Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. the lung health study.JAMA. 1994; 272: 1497-1505https://doi.org/10.1001/jama.272.19.1497
- Decline of FEV1 by age and smoking status: facts, figures, and fallacies.Thorax. 1997; 52: 820-827https://doi.org/10.1136/thx.52.9.820
- Evaluating area-based socioeconomic status indicators for monitoring disparities within health care systems: results from a primary care network.Health Serv Res. 2015; 50: 398-417
- Health care safety net in the US.Encyclopedia Health Eco. 2014; : 443-446https://doi.org/10.1016/b978-0-12-375678-7.01006-3
Published online: December 27, 2022
Accepted: December 20, 2022
Received in revised form: October 20, 2022
Received: May 30, 2022
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