Surgery Benefits Even High-Risk Early Lung Cancer Patients

Diana Swift

November 12, 2015

Good clinical outcomes after surgery are possible in high-risk stage I non–small cell lung cancer patients, according to results of a retrospective study published online November 10 in the Annals of Thoracic Surgery.

The researchers suggest that more patients than are currently being offered this option could undergo surgery. At present, 20% of patients with stage I non–small cell lung cancer are deemed inoperable or at high risk for surgery, they note.

"Going forward, these results help justify the advantage of surgical resection in these patients, instead of immediately turning to nonoperative modalities," lead author Manu S. Sancheti, MD, a thoracic and cardiac surgeon and an assistant professor of surgery at Emory University School of Medicine, in Atlanta, Georgia, told Medscape Medical News.

The study found that resection in high-risk patients yielded acceptable 1-, 2-, and 3-year survival rates compared with historical rates for nonsurgical therapies.

Three years post surgery, 59% of high-risk patients were still alive vs 76% of standard-risk patients. Postoperative mortality was virtually the same in high-risk patients (2% for high-risk patients vs 1% for standard-risk patients).

In published data, 3-year survival rates for nonsurgical treatments, such as radiotherapy or ablation, range from 30% to 56%. "Of note, these previous studies did not specifically analyze high-risk patient populations," Dr Sancheti commented.

Significantly, the surgical approach unexpectedly led to nodal upstaging in 20% of patients, allowing them to undergo adjunct chemotherapy. "This study suggests that empiric selection criteria may deny patients optimal oncologic therapy," write Dr Sancheti and his associates. They suggest that a multidisciplinary team should review all cases to determine the best treatment plan for individual patients, adding that other studies have shown improved outcomes in the high-risk population with minimally invasive modalities, such as video-assisted thoracoscopic surgery.

Study Details

The study sample consisted of 490 patients, just more than half women, who underwent resection from 2009 to 2013 for clinical stage I non–small cell lung cancer. Of these, 180 (36.7%) patients were classified as high risk according to American College of Surgery Oncology Group criteria. The latter were older than their standard-risk counterparts (69.8 years vs 65.3 years) and had worse forced expiratory volume in 1 second (57% vs 85%, P < .0001) or poorer diffusing capacity of lung for carbon dioxide (47% vs 77%, P < .0001). They were more likely to undergo sublobar resection (32% vs 20%, p = .001).

High-risk patients also had more pack-years of smoking than standard-risk patients (46 vs 30, P < .0001), and the incidence of chronic obstructive pulmonary disease was greater among the high-risk patients (72% vs 32%, P < .0001).

Despite essentially the same inhospital morality rate (2% vs 1%, P = 0.53), high-risk patients had increased rates of minor and major morbidity ― more than double the incidence of major morbidities of their standard-risk counterparts (15.5% vs 6.7%, P < .01).

Length of hospital stay was longer in the high-risk group (5 days vs 4 days, P < . 0001), affecting costs.

In considering the applicability of these results to community cancer centers, Dr Sancheti said that previous studies have shown a slight short- and long-term survival advantage in patients who underwent resection at academic, National Cancer Institute–designated centers vs community cancer settings. "Nevertheless, I think our current study's data are applicable to a community setting. Most importantly, the inclusion of the thoracic surgeon, whether in a community setting or an academic environment, is vital for the development of the treatment plan for these patients."

The researchers also call for better definition of the classification and treatment of high-risk patients. "We believe that it is the onus of thoracic surgeons to lead continued investigations into improvements in risk stratification, as well as to delineate the most efficacious treatment, with resection at the forefront," they write.

Dr Sancheti said, "High-risk patients have a new treatment avenue that previously may have been denied to them."

Commenting on the study, Gregory A. Masters, MD, a medical oncologist who helps design lung cancer treatment plans with a multidisciplinary team at Christiana Health Care's Helen F. Graham Cancer Center, in Newark, Delaware, agreed that despite effective alternatives for controlling early tumors, such as stereotactic radiation, surgery remains the standard of care for those able to undergo resection. "But there's still a lot of question about whether these borderline-performance patients can get through surgery," Dr Masters told Medscape Medical News. "This paper confirms that surgery is still a good option for them. We're not at the point of automatically jumping to radiation for patients who have a bit of pulmonary compromise."

He, too, stressed the importance of evaluating patients for surgery vs other treatment with a multidisciplinary team.

Dr Sancheti and most coauthors have disclosed no relevant financial relationships. One coauthor has a financial relationship with Ethicon, Inc. Dr Masters has disclosed no relevant financial relationships.

Ann Thorac Surg. Published online November 10, 2015. Abstract

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