Wakeam E, Varghese T K, Leighl N B, Giuliani M, Finlayson S R G, Darling G E
Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
Department of Surgery, University of Utah, Salt Lake City, UT, United States; Division of Thoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States.
Lung Cancer. 2017 Jul;109:117-123. doi: 10.1016/j.lungcan.2017.05.004. Epub 2017 May 13.
Practice guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend pathologic mediastinal staging and surgical resection for patients with clinically node-negative T1/T2 small cell lung cancer (SCLC), but the extent to which surgery is used is unknown. We sought to assess trends and practice patterns in the use of surgery for SCLC.
T1 or T2N0M0 SCLC cases were identified in the National Cancer Database (NCDB), 2004-2013. Characteristics of patients undergoing resection were analyzed. Hierarchical logistic regression was used to identify individual and hospital-level predictors of receipt of surgery, adjusting for clinical, demographic and facility characteristics. Trends in resection rates were analyzed over the study period.
9740 patients were identified with clinical T1 or T2 N0M0 SCLC. Of these, 2210 underwent surgery (22.7%), with 1421 (64.3%) undergoing lobectomy, 739 (33.4%) sublobar resections and 50 (2.3%) pneumonectomies. After adjustment, Medicaid patients were less likely to receive surgery (OR0.65 95% CI 0.48-0.89, p=0.006), as were those with T2 tumors (OR0.25 CI0.22-0.29, p<0.0001). Academic facilities were more likely to resect eligible patients (OR 1.90 CI1.45-2.49, p<0.0001). Between 2004 and 2013, resection rates more than doubled from 9.1% to 21.7%. Overall, 68.7% of patients were not offered surgery despite having no identifiable contraindication. In patients not receiving surgery, only 7% underwent pathologic mediastinal staging.
Rates of resection are increasing, but two thirds of potentially eligible patients fail to undergo surgery. Further study is required to address the lack of concordance between guidelines and practice.
美国国立综合癌症网络和美国临床肿瘤学会的实践指南推荐，对于临床淋巴结阴性的T1/T2期小细胞肺癌（SCLC）患者，应进行纵隔病理分期和手术切除，但手术的使用程度尚不清楚。我们试图评估SCLC手术治疗的趋势和实践模式。
在2004 - 2013年的国家癌症数据库（NCDB）中识别出T1或T2N0M0期SCLC病例。分析接受手术患者的特征。采用分层逻辑回归来确定接受手术的个体和医院层面的预测因素，并对临床、人口统计学和机构特征进行调整。分析研究期间手术切除率的趋势。
共识别出9740例临床T1或T2 N0M0期SCLC患者。其中，2210例接受了手术（22.7%），1421例（64.3%）接受了肺叶切除术，739例（33.4%）接受了肺段以下切除术，50例（2.3%）接受了全肺切除术。调整后，医疗补助患者接受手术的可能性较小（OR 0.65，95% CI 0.48 - 0.89，p = 0.006），T2期肿瘤患者也是如此（OR 0.25，CI 0.22 - 0.29，p < 0.0001）。学术机构更有可能切除符合条件的患者（OR 1.90，CI 1.45 - 2.49，p < 0.0001）。2004年至2013年期间，切除率从9.1%增加了一倍多，达到21.7%。总体而言，68.7%的患者尽管没有明显的手术禁忌证，但仍未接受手术。在未接受手术的患者中，只有7%进行了纵隔病理分期。
手术切除率在上升，但三分之二的潜在合适患者未能接受手术。需要进一步研究以解决指南与实践之间缺乏一致性的问题。
