Dhanasopon Andrew P, Salazar Michelle C, Hoag Jessica R, Rosen Joshua E, Kim Anthony W, Detterbeck Frank C, Blasberg Justin D, Boffa Daniel J
Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Cancer Outcomes, Public Policy, and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
Ann Thorac Surg. 2017 Dec;104(6):1829-1836. doi: 10.1016/j.athoracsur.2017.06.073. Epub 2017 Nov 1.
Lung cancer patients rely on survival estimates to weigh risks and benefits of treatment. However, pneumonectomy-requiring lung cancer may have inherent oncologic or physiologic survival implications not captured by the current stage classification. Stage-specific survival was evaluated to refine survival expectations for patients with pneumonectomy-requiring disease.
The National Cancer Database was queried for treatment-naive patients who underwent lobectomy or pneumonectomy for stage I to III non-small cell lung cancer between 2004 and 2013. Patients who died within 90 days after resection were excluded. Three-way propensity score weighted multivariable Cox models were built and incorporated into adjusted 5-year overall survival (OS) curves.
A total of 79,953 patients met inclusion criteria: 75,708 lobectomies (95%) and 4,245 pneumonectomies (5%). Stage I and II patients undergoing right pneumonectomy had worse adjusted 5-year OS than patients undergoing left pneumonectomy, which was worse than lobectomy (stage I: 55%, 58%, 67%; stage II: 37%, 44%, 48%; indicating right pneumonectomy, left pneumonectomy, lobectomy). Stage III right pneumonectomy patients had worse adjusted 5-year OS; however, left pneumonectomy and lobectomy patients were similar (33%, 39%, 40%). A doubly robust Cox model identified a similar pattern for mortality risk for stage I and II (right pneumonectomy > left > lobectomy); however, stage III right pneumonectomy patients had higher mortality risk than lobectomy patients (hazard ratio [HR] 1.23, 95% confidence interval [CI]: 1.17 to 1.28, p < 0.001), whereas left pneumonectomy was similar to lobectomy (HR 1.02, 95% CI: 0.97 to 1.06, p = 0.47).
Pneumonectomy-requiring lung cancer embodies a 5-year mortality risk not completely captured by the lung cancer staging system. Refined survival estimates for pneumonectomy patients may enhance shared decision making in this population.
肺癌患者依靠生存预估来权衡治疗的风险与益处。然而，需要进行肺切除术的肺癌可能存在当前分期系统未涵盖的内在肿瘤学或生理学生存影响因素。对特定分期的生存率进行评估，以完善对需要进行肺切除术的患者的生存预期。
查询国家癌症数据库，筛选出2004年至2013年间接受I至III期非小细胞肺癌肺叶切除术或肺切除术且未接受过治疗的患者。排除术后90天内死亡的患者。构建了三向倾向评分加权多变量Cox模型，并纳入调整后的5年总生存（OS）曲线。
共有79,953例患者符合纳入标准：75,708例肺叶切除术（95%）和4,245例肺切除术（5%）。接受右肺切除术的I期和II期患者调整后的5年总生存率低于接受左肺切除术的患者，而左肺切除术患者的生存率又低于接受肺叶切除术的患者（I期：55%、58%、67%；II期：37%、44%、48%；分别表示右肺切除术、左肺切除术、肺叶切除术）。III期右肺切除术患者调整后的5年总生存率较差；然而，左肺切除术患者和肺叶切除术患者的生存率相似（33%、39%、40%）。双重稳健Cox模型在I期和II期患者中确定了类似的死亡风险模式（右肺切除术＞左肺切除术＞肺叶切除术）；然而，III期右肺切除术患者的死亡风险高于肺叶切除术患者（风险比[HR] 1.23，95%置信区间[CI]：1.17至1.28，p＜0.001），而左肺切除术与肺叶切除术相似（HR 1.02，95% CI：0.97至1.06，p = 0.47）。
需要进行肺切除术的肺癌存在肺癌分期系统未完全涵盖的5年死亡风险。对肺切除术患者进行更精确的生存预估可能会改善该人群的共同决策。
