Survival Reduced in Lung Cancer Patients Who Refuse Surgery

Pam Harrison

October 04, 2018

TORONTO — The small percentage of patients with clinical stage I lung cancer who refuse surgery have much worse survival outcomes compared with those who undergo an operation, a new analysis shows.

"We are increasingly seeing patients recommended for lung cancer surgery who are anxious about surgery, and I think there is a fear and misunderstanding of the operation," Brendon Stiles, MD, associate professor of thoracic surgery, Weill Cornell Medicine and the New York–Presbyterian Hospital, New York City, told Medscape Medical News.

"So we undertook this study to try and answer patients who ask, 'What happens if I don't do surgery?' " he added.

"And while patients may rightfully wish to avoid the morbidity and quality-of-life issues associated with surgery, we found that this may come at the expense of decreased survival," Stiles said.

The study was presented at the 19th World Conference on Lung Cancer (WCLC) here.

Investigators analyzed data from the National Cancer Database (NCD) to determine what proportion of patients with operable clinical stage I lung cancer refused surgery for whatever reason.

They then compared demographics and overall survival (OS) between those who accepted surgery and those who refused.

Of 121,231 patients with lung cancer in the NCD between 2004 and 2014, 2.6% refused surgery. The reasons for refusal were unknown.

Of this small cohort of patients, 43% refused treatment of any kind, 26% received radiotherapy or chemotherapy alone, 24% underwent stereotactic radiotherapy, and 7% received chemoradiotherapy.

Median OS for the entire cohort was 81 months, Stiles reported.

However, there was a significant difference between median OS rates for patients who underwent surgery and those who chose some other form of treatment.

Table 1. Median OS Stratified by Treatment

Surgery 83 months
Stereotactic radiotherapy 48 months
Other (chemotherapy/radiotherapy or chemoradiotherapy) 25 months


Stereotactic Radiotherapy on the Rise

"It is not surprising that there were some demographic differences between those who got surgery and those who refused," Stiles continued.

For example, those who refused surgery were older, less likely to be white, and more likely to lack insurance coverage.

Interestingly, those with squamous cell cancer as well as those with larger tumors were also more likely to refuse surgery, Stiles noted.

Table 2. Predictors of Refusing Lung Cancer Surgery

Variable Odds Ratio P Value
Increasing age 1.09 <.001
Non-white race 2.18 <.001
Low income 1.28 <.001
Lack of insurance 2.62 <.001
Squamous histology 1.40 <.001
Large tumor size 1.57 <.001


Stiles also noted that the proportion of patients who refused surgery and who underwent stereotactic radiotherapy instead has been increasing over time, from 3.8% in 2004-2006 to 37.9% in 2013-2014.

The investigators therefore wondered whether part of the reason why patients were refusing surgery was that, over time, more of them were being offered stereotactic radiotherapy instead of surgery.

In a propensity-matched analysis of 571 patients, the investigators found that outcomes following stereotactic radiotherapy were not as good as those following surgery. The median OS was 66 months for patients who underwent surgery, vs 48 months for those who underwent stereotactic radiotherapy.

"I think that each patient needs to be considered individually, so it's important to have a conversation and to try to give patients the data," Stiles suggested.

"And while there is a small mortality risk with surgery, I think it's sometimes underappreciated that there is some risk with radiation too, in terms of toxicity to the lung and pneumonitis, so sharing this information with patients and helping them understand the relative risk of both procedures is very important," he said.

Discussant Steven Lin, MD, PhD, associate professor of radiation oncology, MD Anderson Cancer Center in Houston, Texas, also felt that it was very important for patients who opt for surgery to discuss the short-term mortality risk with patients, especially those older than 70 years, who are most at risk for early mortality following lung cancer surgery.

However, Lin also suggested that stereotactic radiotherapy may well be an acceptable alternative to surgery, because some studies have suggested that patients who refuse surgery do relatively well with the stereotactic procedure.

"Patients have to be well staged ahead of time, so you need to make sure they have early-stage cancer," Lin cautioned.

"But I think these patients can do reasonably well with stereotactic radiation alone," he said.

"On the other hand, I do agree that determining operability is up for discussion and that it should be part of the shared decision making between surgeon and patient," Lin concluded.

Dr Stiles has received advisory board fees from Merck and AstraZeneca, and his wife has received fees and has stock in Pfizer and PPD. Dr Lin has received research grants from STCube Pharmaceuticals, Hitachi Chemical Diagnostics, Genentech, New River Labs, and Beyond Spring Pharmaceuticals and advisory board fees from AstraZeneca and New River Labs.

19th World Conference on Lung Cancer (WCLC). Abstract OA06.07, presented September 24, 2018.


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