Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina.
Ann Thorac Surg. 2018 Nov;106(5):1533-1540. doi: 10.1016/j.athoracsur.2018.05.066. Epub 2018 Jun 28.
Lobar resection is the gold standard therapy for medically fit patients with stage I non-small cell lung cancer (NSCLC). However, considerable variability exists in the use of surgical therapy. This study tested the hypothesis that center-based variation in the use of surgical therapy affects survival in NSCLC.
We queried the National Cancer Database for patients with stage I NSCLC. Mixed-effects multivariable models were developed to establish the per-center adjusted rate of surgical therapy. Patients were stratified into quartiles based on the treating center's adjusted rate of surgical therapy. Survival was estimated and then tested by using Kaplan-Meier and the log-rank test. Multivariable Cox proportional hazard models were developed to estimate the effect of rate of surgical therapy on overall survival.
A total of 139,802 patients met the criteria. There was wide variation in the per-center rate of surgical resection in the highest (80.8%) versus lowest (41.4%, p < 0.001) quartile. Across cohorts, patients were similar in age (mean 68.8 years in the highest quartile versus 69.7 in the lowest quartile) and Charlson-Deyo Score of 2 or greater (15.1% in the highest quartile versus 14.4% in the lowest quartile). Five-year survival was higher for patients treated at high-use centers (52.7% versus 36.7%, p < 0.001). After adjustment, an adjusted rate of surgical therapy in the lowest 25th percentile was associated with lower survival (adjusted hazard ratio 1.40, 95% confidence interval: 1.37 to 1.40, p < 0.001).
Treatment at a center with a higher rate of surgical therapy confers a considerable survival advantage, even after adjustment for hospital volume, surgical approach, and other confounders. Targeted efforts to improve adherence to guidelines about provision of surgical therapy in early-stage NSCLC may represent a meaningful opportunity to improve outcomes.
肺叶切除术是适合医学治疗的 I 期非小细胞肺癌 (NSCLC) 患者的金标准治疗方法。然而，在手术治疗的应用中存在相当大的差异。本研究检验了这样一个假设，即中心之间手术治疗应用的差异会影响 NSCLC 的生存。
我们查询了国家癌症数据库中 I 期 NSCLC 患者的资料。建立了混合效应多变量模型，以确定每中心手术治疗的调整率。根据治疗中心手术治疗的调整率，将患者分为四组。使用 Kaplan-Meier 和对数秩检验估计并检验生存情况。建立多变量 Cox 比例风险模型来估计手术治疗率对总生存的影响。
共有 139802 名患者符合标准。在最高（80.8%）和最低（41.4%，p<0.001）四分位中心之间，手术切除的中心间率差异很大。在各队列中，患者的年龄（最高四分位数为 68.8 岁，最低四分位数为 69.7 岁）和 Charlson-Deyo 评分≥2（最高四分位数为 15.1%，最低四分位数为 14.4%）相似。在高使用率中心接受治疗的患者五年生存率更高（52.7% vs 36.7%，p<0.001）。调整后，最低 25%分位的手术治疗率与较低的生存率相关（调整后的危险比 1.40，95%置信区间：1.37 至 1.40，p<0.001）。
在手术治疗率较高的中心接受治疗可显著提高生存率，即使在调整了医院容量、手术方式和其他混杂因素后也是如此。有针对性地努力提高对早期 NSCLC 提供手术治疗的指南的遵从度，可能是改善结果的一个有意义的机会。
