William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands.
J Clin Oncol. 2018 Mar 1;36(7):642-651. doi: 10.1200/JCO.2017.75.6536. Epub 2018 Jan 18.
Purpose In early-stage non-small cell lung cancer (NSCLC), post-treatment mortality may influence the comparative effectiveness of surgery and stereotactic body radiotherapy (SBRT), with implications for shared decision making among high-risk surgical candidates. We analyzed early mortality after these interventions using the National Cancer Database. Patients and Methods We abstracted patients with cT1-T2a, N0, M0 NSCLC diagnosed between 2004 and 2013 undergoing either surgery or SBRT. Thirty-day and 90-day post-treatment mortality rates were calculated and compared using Cox regression and propensity score-matched analyses. Results We identified 76,623 patients who underwent surgery (78% lobectomy, 20% sublobar resection, 2% pneumonectomy) and 8,216 patients who received SBRT. In the unmatched cohort, mortality rates were moderately increased with surgery versus SBRT (30 days, 2.07% v 0.73% [absolute difference (Δ), 1.34%]; P < .001; 90 days, 3.59% v 2.93% [Δ, 0.66%]; P < .001). Among the 27,200 propensity score-matched patients, these differences increased (30 days, 2.41% v 0.79% [Δ, 1.62%]; P < .001; 90 days, 4.23% v 2.82% [Δ, 1.41%]; P < .001). Differences in mortality between surgery and SBRT increased with age, with interaction P < .001 at both 30 days and 90 days (71 to 75 years old: 30-day Δ, 1.87%; 90-day Δ, 2.02%; 76 to 80 years old: 30-day Δ, 2.80%; 90-day Δ, 2.59%; > 80 years old: 30-day Δ, 3.03%; 90-day Δ, 3.67%; all P ≤ .001). Compared with SBRT, surgical mortality rates were higher with increased extent of resection (30-day and 90-day multivariate hazard ratio for mortality: sublobar resection, 2.85 and 1.37; lobectomy, 3.65 and 1.60; pneumonectomy, 14.5 and 5.66; all P < 0.001). Conclusion Differences in 30- and 90-day post-treatment mortality between surgery and SBRT increased as a function of age, with the largest differences in favor of SBRT observed among patients older than 70 years. These representative mortality data may inform shared decision making among patients with early-stage NSCLC who are eligible for both interventions.
目的 在早期非小细胞肺癌（NSCLC）中，治疗后死亡率可能会影响手术和立体定向体部放射治疗（SBRT）的比较效果，这对高危手术候选者的共同决策具有重要意义。我们利用国家癌症数据库分析了这些干预措施后的早期死亡率。
患者和方法 我们从 2004 年至 2013 年间诊断为 cT1-T2a、N0、M0 NSCLC 的患者中提取了接受手术或 SBRT 的患者。使用 Cox 回归和倾向评分匹配分析计算并比较了 30 天和 90 天的治疗后死亡率。
结果 我们确定了 76623 例接受手术（78%为肺叶切除术，20%为亚肺叶切除术，2%为全肺切除术）和 8216 例接受 SBRT 的患者。在未匹配的队列中，手术与 SBRT 相比死亡率略有升高（30 天为 2.07%比 0.73%[绝对差值（Δ），1.34%]；P<0.001；90 天为 3.59%比 2.93%[Δ，0.66%]；P<0.001）。在 27200 例倾向评分匹配的患者中，这些差异有所增加（30 天为 2.41%比 0.79%[Δ，1.62%]；P<0.001；90 天为 4.23%比 2.82%[Δ，1.41%]；P<0.001）。手术和 SBRT 之间的死亡率差异随着年龄的增长而增加，30 天和 90 天的交互 P<0.001（71 至 75 岁：30 天Δ，1.87%；90 天Δ，2.02%；76 至 80 岁：30 天Δ，2.80%；90 天Δ，2.59%；>80 岁：30 天Δ，3.03%；90 天Δ，3.67%；均 P<0.001）。与 SBRT 相比，手术死亡率随着切除范围的增加而升高（30 天和 90 天的死亡多变量风险比：亚肺叶切除术为 2.85 和 1.37；肺叶切除术为 3.65 和 1.60；全肺切除术为 14.5 和 5.66；均 P<0.001）。
结论 手术和 SBRT 之间 30 天和 90 天治疗后死亡率的差异随着年龄的增长而增加，年龄>70 岁的患者中，SBRT 的优势最大。这些有代表性的死亡率数据可能会为符合两种干预条件的早期 NSCLC 患者的共同决策提供信息。
