Winship Cancer Institute, Emory University, Atlanta, GA; Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA.
Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, GA; Department of Data Science, Dana Farber Cancer Institute (current institutional affiliation), Boston, MA.
Clin Lung Cancer. 2022 May;23(3):e231-e237. doi: 10.1016/j.cllc.2021.12.012. Epub 2022 Jan 10.
Operability is both a crucial determinant in treatment selection and a potential confounder in analyses comparing surgery with non-surgical approaches such as stereotactic body radiotherapy (SBRT). We aimed to assess the association between operability status and intervention with post-treatment mortality in early-stage non-small cell lung cancer (NSCLC).
We defined four groups of patients with cT1-T2N0M0 NSCLC diagnosed 2010 to 2014 from the National Cancer Database: SBRT patients deemed operable vs. inoperable and surgery patients receiving open vs. minimally-invasive approaches. Mortality rates at 30, 60, and 90 days post-treatment were calculated and compared.
We abstracted 80,108 patients, 0.8% undergoing SBRT and operable, 13.2% undergoing SBRT and inoperable, 52.4% undergoing open surgery, and 33.7% undergoing minimally-invasive surgery. Mortality rates were highest among open surgery patients and lowest among operable SBRT patients (2.0% vs. 0.2% at 30 days and 3.7% vs. 0.7% at 90 days), with intermediate results in the other two groups. These findings persisted on multivariate Cox regression: compared to patients undergoing minimally-invasive surgery, mortality risk was highest among open surgery patients (30 days HR 1.32, 95%CI 1.16-1.51; 90 days HR 1.36, 95%CI 1.24-1.50; both P < .001) and lowest among operable SBRT patients (30 days HR 0.09, 95%CI 0.01-0.64; 90 days HR 0.15, 95%CI 0.05-0.46; both P ≤ .016). These associations were maintained in a propensity score-matched subset.
Operable patients undergoing SBRT experience minimal post-treatment mortality compared to their inoperable counterparts. These findings illustrate the potential for confounding by operability to bias results in cohort studies that compare surgical vs. non-surgical approaches in early-stage NSCLC.
可操作性不仅是治疗选择的关键决定因素，也是比较手术与立体定向体放射治疗（SBRT）等非手术方法的分析中的一个潜在混杂因素。我们旨在评估早期非小细胞肺癌（NSCLC）患者的可操作性与治疗后死亡率之间的关联。
我们从国家癌症数据库中定义了 2010 年至 2014 年间诊断为 cT1-T2N0M0 NSCLC 的四组患者：SBRT 患者被认为是可手术的与不可手术的，以及接受开放手术与微创手术的手术患者。计算并比较了治疗后 30、60 和 90 天的死亡率。
我们提取了 80108 名患者，其中 0.8%接受 SBRT 且可手术，13.2%接受 SBRT 且不可手术，52.4%接受开放手术，33.7%接受微创手术。死亡率最高的是开放手术患者，最低的是可手术 SBRT 患者（30 天分别为 2.0%和 0.2%，90 天分别为 3.7%和 0.7%），其他两组的结果介于两者之间。这些发现经多变量 Cox 回归分析后仍然存在：与接受微创手术的患者相比，开放手术患者的死亡率最高（30 天 HR 1.32，95%CI 1.16-1.51；90 天 HR 1.36，95%CI 1.24-1.50；均 P <.001），而可手术 SBRT 患者的死亡率最低（30 天 HR 0.09，95%CI 0.01-0.64；90 天 HR 0.15，95%CI 0.05-0.46；均 P ≤.016）。这些关联在倾向评分匹配的子集中得到了维持。
与不可手术的对应者相比，接受 SBRT 的可手术患者的治疗后死亡率最小。这些发现说明了在比较早期 NSCLC 中手术与非手术方法的队列研究中，可操作性偏倚可能会影响结果。
