David Elizabeth A, Daly Megan E, Li Chin-Shang, Chiu Chi-Lu, Cooke David T, Brown Lisa M, Melnikow Joy, Kelly Karen, Canter Robert J
Section of General Thoracic Surgery and Outcomes Research Group, Department of Surgery, University of California Davis Medical Center, Sacramento, California; Heart Lung Vascular Center, David Grant Medical Center, Travis Air Force Base, California.
Department of Radiation Oncology, University of California Davis Medical Center, Sacramento, California.
J Thorac Oncol. 2017 Mar;12(3):437-445. doi: 10.1016/j.jtho.2016.11.2221. Epub 2017 Jan 18.
Variation in treatment and survival outcomes for NSCLC is high among patients with stage III or IV disease, but patients with untreated NSCLC have not been critically analyzed to evaluate for improvable outcomes. We evaluated treatment trends and their association with oncologic outcomes for NSCLC, hypothesizing that there are a substantial number of untreated patients who are similar to patients who undergo treatment.
Linear regression was used to calculate trends in utilization of treatment. Kaplan-Meier and Cox regression modeling were used to determine predictors of receiving treatment. Propensity matching was used to compare survival among subsets of treated versus untreated patients.
Patients with primary NSCLC were identified from the National Cancer Data base from 1998 to 2012, and 21% of patients (190,539) received no treatment. For stage IIIA and IV, the proportion of untreated patients increased over the study period by 0.21% and 0.4%, respectively (p = 0.003 and p < 0.0001). Regardless of stage, untreated patients had significantly shorter overall survival (OS) (p < 0.0001). Propensity-matched analyses of 6144 stage IIIA patient pairs treated with chemoradiation versus no treatment confirmed shorter OS for untreated patients (median 16.5 versus 6.1 months, p < 0.0001). For 19,046 stage IV patient pairs treated with chemotherapy versus no treatment, similar results were obtained (median OS 9.3 versus 2.0 months, p < 0.0001).
The proportion of untreated patients with stage IIIA and IV disease is increasing. Survival outcomes among patients with advanced-stage disease are superior with treatment, independent of selection bias. The benefits and risks of treatment should be carefully assessed before choosing to forego treatment.
Ⅲ期或Ⅳ期非小细胞肺癌（NSCLC）患者的治疗及生存结局差异很大，但未经治疗的NSCLC患者尚未得到严格分析以评估是否能改善结局。我们评估了NSCLC的治疗趋势及其与肿瘤学结局的关联，推测存在大量未经治疗的患者，他们与接受治疗的患者相似。
采用线性回归计算治疗利用趋势。使用Kaplan-Meier法和Cox回归模型确定接受治疗的预测因素。采用倾向匹配法比较接受治疗与未接受治疗患者亚组的生存率。
从1998年至2012年的国家癌症数据库中确定了原发性NSCLC患者，21%的患者（190,539例）未接受治疗。对于ⅢA期和Ⅳ期，在研究期间未接受治疗患者的比例分别增加了0.21%和0.4%（p = 0.003和p < 0.0001）。无论处于何阶段，未接受治疗的患者总生存期（OS）均显著缩短（p < 0.0001）。对6144对接受放化疗与未接受治疗的ⅢA期患者进行倾向匹配分析，证实未接受治疗的患者OS较短（中位生存期16.5个月对6.1个月，p < 0.0001）。对于19,046对接受化疗与未接受治疗的Ⅳ期患者，也得到了类似结果（中位OS 9.3个月对2.0个月，p < 0.0001）。
ⅢA期和Ⅳ期未接受治疗患者的比例正在增加。晚期疾病患者接受治疗后的生存结局更佳，且不受选择偏倚影响。在选择放弃治疗之前，应仔细评估治疗的益处和风险。
