Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo.
Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.
JAMA Netw Open. 2022 Sep 1;5(9):e2230704. doi: 10.1001/jamanetworkopen.2022.30704.
National guidelines allow consideration of postoperative radiation therapy (PORT) among patients with incompletely resected non-small cell lung cancer (NSCLC). However, there is a paucity of prospective data because recently completed trials excluded patients with positive surgical margins. In addition, unlike for locally advanced NSCLC, the role of intensity-modulated radiation therapy (IMRT) for PORT remains unclear.
To evaluate trends of IMRT use for PORT in the US and the association of IMRT with survival outcomes among patients with incompletely resected NSCLC.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from the National Cancer Database for patients diagnosed between January 2004 and December 2019 with incompletely resected NSCLC who underwent upfront surgery with positive surgical margins followed by PORT.
IMRT vs 3D conformal radiation therapy (3DCRT) for PORT.
The main outcome was overall survival. Multivariable Cox proportional hazards regression assessed the association of IMRT vs 3DCRT with overall survival. Multivariable logistic regression identified variables associated with IMRT. Propensity score matching (1:1) was performed based on variables of interest.
A total of 4483 patients (2439 men [54.4%]; median age, 67 years [IQR, 60-73 years]) were included in the analysis. Of those, 2116 (47.2%) underwent 3DCRT and 2367 (52.8%) underwent IMRT. Median follow-up was 48.5 months (IQR, 31.1-77.2 months). The proportion of patients who underwent IMRT increased from 14.3% (13 of 91 patients) in 2004 to 70.7% (33 of 471 patients) in 2019 (P < .001). IMRT was associated with improved overall survival compared with 3DCRT (adjusted hazard ratio, 0.84; 95% CI, 0.78-0.91; P < .001). Similar findings were observed for 1463 propensity score-matched pairs; IMRT was associated with improved 5-year overall survival compared with 3DCRT (37.3% vs 32.2%; hazard ratio, 0.88; 95% CI, 0.80-0.96; P = .003). IMRT use was associated with receipt of treatment at an academic facility (adjusted odds ratio [aOR], 1.15; 95% CI, 1.00-1.33; P = .049), having T4 stage tumors (aOR, 1.50; 95% CI, 1.13-1.99; P = .005) or N2 or N3 stage tumors (aOR, 1.25; 95% CI, 1.04-1.51; P = .02), and receipt of pneumonectomy (aOR, 1.35; 95% CI, 1.02-1.80; P = .04).
This cohort study found that use of IMRT for PORT among patients with incompletely resected NSCLC increased in the US from 2004 to 2019 and was associated with improved survival compared with 3DCRT. Further studies are warranted to investigate the role of different radiation therapy techniques for PORT.
国家指南允许考虑在不完全切除的非小细胞肺癌 (NSCLC) 患者中进行术后放疗 (PORT)。然而，由于最近完成的试验排除了阳性切缘的患者，因此前瞻性数据很少。此外，与局部晚期 NSCLC 不同，IMRT 用于 PORT 的作用仍不清楚。
评估美国 IMRT 用于 PORT 的趋势以及 IMRT 与不完全切除的 NSCLC 患者生存结果之间的关联。
设计、地点和参与者：这项回顾性队列研究使用了国家癌症数据库的数据，纳入了 2004 年 1 月至 2019 年 12 月期间接受过阳性切缘的不完全切除 NSCLC 手术且随后接受 PORT 的患者。
PORT 时使用 IMRT 与 3D 适形放疗 (3DCRT)。
主要结局是总生存。多变量 Cox 比例风险回归评估了 IMRT 与 3DCRT 与总生存的关联。多变量逻辑回归确定了与 IMRT 相关的变量。根据感兴趣的变量进行倾向评分匹配（1:1）。
共纳入 4483 例患者（2439 例男性[54.4%]；中位年龄 67 岁[IQR，60-73 岁]）。其中，2116 例（47.2%）接受 3DCRT，2367 例（52.8%）接受 IMRT。中位随访时间为 48.5 个月（IQR，31.1-77.2 个月）。2004 年接受 IMRT 的患者比例为 14.3%（91 例中的 13 例），2019 年增至 70.7%（471 例中的 33 例）（P < .001）。与 3DCRT 相比，IMRT 与改善的总生存相关（调整后的危险比，0.84；95%CI，0.78-0.91；P < .001）。在 1463 对匹配的倾向评分中也观察到了类似的结果；与 3DCRT 相比，IMRT 与 5 年总生存改善相关（37.3%比 32.2%；危险比，0.88；95%CI，0.80-0.96；P = .003）。IMRT 的使用与在学术机构接受治疗相关（调整后的优势比[aOR]，1.15；95%CI，1.00-1.33；P = .049），T4 期肿瘤（aOR，1.50；95%CI，1.13-1.99；P = .005）或 N2 或 N3 期肿瘤（aOR，1.25；95%CI，1.04-1.51；P = .02），以及全肺切除术（aOR，1.35；95%CI，1.02-1.80；P = .04）。
这项队列研究发现，2004 年至 2019 年，美国不完全切除的 NSCLC 患者中 IMRT 用于 PORT 的使用率增加，与 3DCRT 相比，生存率得到改善。需要进一步研究以探讨不同放疗技术在 PORT 中的作用。
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