Till Brian M, Whitehorn Gregory, Mack Shale J, Thosani Darshak, Rahman Uzma, Grenda Tyler, Evans Nathaniel R, Okusanya Olugbenga T
Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Philadelphia, Pennsylvania.
Sidney Kimmel Medical College, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2023 Feb;115(2):347-354. doi: 10.1016/j.athoracsur.2022.07.053. Epub 2022 Aug 24.
Increasingly, stereotactic body radiation therapy (SBRT) is used for patients unfit for or unwilling to undergo operation for early-stage non-small cell lung cancer. It remains unclear how SBRT utilization has influenced patient refusal of surgical resection.
A retrospective cohort analysis was completed using the National Cancer Database for patients with T1/T2 N0 M0 lesions from 2008 to 2017. Facilities were categorized into tertiles by SBRT/surgery ratio for each year of analysis. Propensity score matching was used to compare rates of surgical refusal and rates of postrefusal receipt of SBRT. Multivariable regression analysis was performed to evaluate effect size.
The study included 129 901 patients; 63 048 were treated at low-tertile SBRT/surgery facilities, 41 674 at middle-tertile SBRT/surgery facilities, and 25 179 at high-tertile SBRT/surgery facilities. Patients refusing surgery at high SBRT/surgery facilities had fewer comorbid conditions and smaller tumors. Rates of SBRT after surgical refusal differed (low SBRT/surgery facilities, 17.2%; high SBRT/surgery facilities, 55.9%; P < .001). In a matched cohort of 76 636, surgical refusal differed (low SBRT/surgery facilities, 4.2%; high SBRT/surgery facilities, 6.0%; P < .001). On multivariable regression, treatment at a top-tertile SBRT/surgery facility was the largest risk factor for surgical refusal (odds ratio, 3.82 [3.53-4.13]; P < .001) and was most strongly associated with postrefusal receipt of SBRT (odds ratio, 6.11 [5.09-7.34]; P < .001).
Patients treated at high SBRT-using facilities are more likely to refuse surgical resection and more likely to receive radiation therapy after surgical refusal. Further analysis is needed to better understand patient refusal of surgery in the setting of early-stage non-small cell lung cancer.
立体定向体部放射治疗（SBRT）越来越多地用于不适合或不愿接受早期非小细胞肺癌手术的患者。SBRT的应用如何影响患者拒绝手术切除尚不清楚。
利用国家癌症数据库对2008年至2017年患有T1/T2 N0 M0病变的患者进行回顾性队列分析。在每年的分析中，根据SBRT/手术比例将医疗机构分为三分位数。采用倾向评分匹配法比较手术拒绝率和拒绝手术后接受SBRT的比例。进行多变量回归分析以评估效应大小。
该研究纳入了129901例患者；63048例在低SBRT/手术比例的医疗机构接受治疗，41674例在中等SBRT/手术比例的医疗机构接受治疗，25179例在高SBRT/手术比例的医疗机构接受治疗。在高SBRT/手术比例的医疗机构拒绝手术的患者合并症较少，肿瘤较小。手术拒绝后接受SBRT的比例有所不同（低SBRT/手术比例的医疗机构为17.2%；高SBRT/手术比例的医疗机构为55.9%；P <.001）。在76636例匹配队列中，手术拒绝率有所不同（低SBRT/手术比例的医疗机构为4.2%；高SBRT/手术比例的医疗机构为6.0%；P <.001）。在多变量回归分析中，在高SBRT/手术比例三分位数的医疗机构接受治疗是手术拒绝的最大风险因素（比值比，3.82[3.53 - 4.13]；P <.001），并且与拒绝手术后接受SBRT的相关性最强（比值比，6.11[5.09 - 7.34]；P <.001）。
在高SBRT应用比例的医疗机构接受治疗的患者更有可能拒绝手术切除，并且在手术拒绝后更有可能接受放射治疗。需要进一步分析以更好地了解早期非小细胞肺癌患者拒绝手术的情况。
