Outcomes of surgery versus chemoradiotherapy in patients with clinical or pathologic stage N3 non–small cell lung cancer

doi:10.1016/j.jtcvs.2019.08.033

The Journal of Thoracic and Cardiovascular Surgery

Volume 158, Issue 6, December 2019, Pages 1680-1692.e2

Read at the 99th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, May 4-7, 2019.

https://doi.org/10.1016/j.jtcvs.2019.08.033 Get rights and content

Under an Elsevier user license

open archive

Abstract

Background

Because surgery is rarely recommended, there is minimal literature comparing the outcomes of surgery and chemoradiation in stage N3 non–small cell lung cancer (NSCLC). We examined the outcomes of definitive chemoradiation versus multimodality therapy, including surgery, for patients with clinical and pathologic stage N3 NSCLC.

Methods

The National Cancer Database was used to identify patients with clinical stage T1 to T3 N3 M0 NSCLC and clinical stage T1 to T3 Nx M0 with pathologic stage N3 NSCLC who were treated with either definitive chemoradiation or surgery between 2004-2015. A 1:1 propensity score-matched analysis was used to compare outcomes for both treatment groups in each analysis. The primary outcome was overall survival.

Results

In 935 matched patient pairs with clinical stage N3 NSCLC, surgery was associated with worse survival (hazard ratio, 1.52; 95% confidence interval, 1.12-2.05) compared with chemoradiation at 6 months, but was associated with a significant survival benefit after 6 months (hazard ratio, 0.54; confidence interval, 0.47-0.63) in multivariable analysis. In 281 pairs of patients with pN3 NSCLC, surgery had similar survival compared with chemoradiation at 6 months (hazard ratio, 1.71; 95% confidence interval, 0.92-3.19), but was associated with improved survival after 6 months (hazard ratio, 0.76; 95% confidence interval, 0.58-0.99). The complete resection rate was 80% and 73% for patients with clinical stage N3 and pathologic stage N3 disease, respectively.

Conclusions

In patients with clinical or pathologic stage N3 NSCLC, surgery is associated with similar or worse short-term but improved long-term survival compared with chemoradiation. In a selected group of patients with stage N3 NSCLC, surgery may have a role in multimodal therapy.

Graphical abstract

In this National Cancer Database study, surgery was associated with improved long-term overall survival compared with chemoradiation in patients with clinical or pathologic N3 disease. This graphical abstract demonstrates the results of propensity score matched-analysis of clinical and pathologic N3 disease patients with hazard ratios and confidence intervals from time-varying multivariable Cox regression presented in tables and Kaplan-Meier survival curves with numbers at risk.

Key Words

non–small cell lung cancer

locally advanced, surgery

multimodal therapy

Abbreviations and Acronyms

clinical

NCDB

Nation Cancer Database

NSCLC

non–small cell lung cancer

pathologic

PACIFIC

Phase III, Randomised, Double-blind, Placebo-controlled, Multi-centre, International Study of MEDI4736 as Sequential Therapy in Patients with Locally Advanced, Unresectable non–Small Cell Lung Cancer (Stage III) Who Have not Progressed Following Definitive, Platinum-based, Concurrent Chemoradiation Therapy

Cited by (0)

: Drs Raman and Voigt were supported by a National Institutes of Health T-32 grant in surgical oncology (No. 5T32CA093245). Dr Jawitz was supported by a National Institutes of Health T-32 grant in clinical research (No. 5T32HL069749).