Samson Pamela, Patel Aalok, Garrett Tasha, Crabtree Traves, Kreisel Daniel, Krupnick A Sasha, Patterson G Alexander, Broderick Stephen, Meyers Bryan F, Puri Varun
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Ann Thorac Surg. 2015 Jun;99(6):1906-12; discussion 1913. doi: 10.1016/j.athoracsur.2015.02.022. Epub 2015 Apr 16.
Conflicting evidence currently exists regarding the causes and effects of delay of care in non-small cell lung cancer (NSCLC). We hypothesized that delayed surgery in early-stage NSCLC is associated with worse short-term and long-term outcomes.
Treatment data of clinical stage I NSCLC patients undergoing surgical resection were obtained from the National Cancer Data Base (NCDB). Treatment delay was defined as resection 8 weeks or more after diagnosis. Propensity score matching for patient and tumor characteristics was performed to create comparable groups of patients receiving early (less than 8 weeks from diagnosis) and delayed surgery. Multivariable regression models were fitted to evaluate variables influencing delay of surgery.
From 1998 to 2010, 39,995 patients with clinical stage I NSCLC received early surgery, while 15,658 patients received delayed surgery. Of these, 27,022 propensity-matched patients were identified. Those with a delay in care were more likely to be pathologically upstaged (18.3% stage 2 or higher versus 16.6%, p < 0.001), have an increased 30-day mortality (2.9% vs 2.4%, p = 0.01), and have decreased median survival (57.7 ± 1.0 months versus 69.2 ± 1.3 months, p < 0.001). Delay in surgery was associated with increasing age, non-white race, treatment at an academic center, urban location, income less than $35,000, and increasing Charlson comorbidity score (p < 0.0001 for all). Delayed patients were more likely to receive a sublobar resection (17.2% vs 13.1%, p < 0.001).
Patients receiving delayed resection for clinical stage I NSCLC have higher comorbidity scores that may affect ability to perform lobectomy and result in higher perioperative mortality. However, delay in resection is independently associated with increased rates of upstaging and decreased median survival. Strategies to minimize delay while medically optimizing higher risk patients are needed.
目前关于非小细胞肺癌（NSCLC）护理延迟的原因和影响存在相互矛盾的证据。我们假设早期NSCLC延迟手术与更差的短期和长期预后相关。
从国家癌症数据库（NCDB）获取接受手术切除的临床I期NSCLC患者的治疗数据。治疗延迟定义为诊断后8周或更长时间进行切除。对患者和肿瘤特征进行倾向评分匹配，以创建接受早期（诊断后少于8周）和延迟手术的可比患者组。采用多变量回归模型评估影响手术延迟的变量。
1998年至2010年，39995例临床I期NSCLC患者接受了早期手术，15658例患者接受了延迟手术。其中，识别出27022例倾向评分匹配的患者。护理延迟的患者更有可能在病理分期上升级（2期或更高期为18.3%，而16.6%，p<0.001），30天死亡率增加（2.9%对2.4%，p=0.01），中位生存期缩短（57.7±1.0个月对69.2±1.3个月，p<0.001）。手术延迟与年龄增加、非白人种族、在学术中心接受治疗、城市地区、收入低于35000美元以及Charlson合并症评分增加相关（所有p<0.0001）。延迟手术的患者更有可能接受肺叶下切除（17.2%对13.1%，p<0.001）。
临床I期NSCLC接受延迟切除的患者合并症评分较高，这可能影响进行肺叶切除术的能力，并导致围手术期死亡率更高。然而，切除延迟与分期升级率增加和中位生存期缩短独立相关。需要采取策略尽量减少延迟，同时在医学上优化高风险患者。
