Trends, practice patterns and underuse of surgery in the treatment of early stage small cell lung cancer

- Surgery is recommended as part of multimodal treatment for T1/T2N0M0 SCLC.
- 2/3 of eligible patients do not receive surgery without documented contraindication.
- Of patients not undergoing surgery, only 7% had pathologic lymph node evaluation.
- Patients in community hospitals or on Medicaid were less likely to undergo surgery.
- Rates of resection have increased almost three-fold in the last ten years.

BackgroundPractice guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend pathologic mediastinal staging and surgical resection for patients with clinically node-negative T1/T2 small cell lung cancer (SCLC), but the extent to which surgery is used is unknown. We sought to assess trends and practice patterns in the use of surgery for SCLC.MethodsT1 or T2N0M0 SCLC cases were identified in the National Cancer Database (NCDB), 2004-2013. Characteristics of patients undergoing resection were analyzed. Hierarchical logistic regression was used to identify individual and hospital-level predictors of receipt of surgery, adjusting for clinical, demographic and facility characteristics. Trends in resection rates were analyzed over the study period.Findings9740 patients were identified with clinical T1 or T2 N0M0 SCLC. Of these, 2210 underwent surgery (22.7%), with 1421 (64.3%) undergoing lobectomy, 739 (33.4%) sublobar resections and 50 (2.3%) pneumonectomies. After adjustment, Medicaid patients were less likely to receive surgery (OR0.65 95% CI 0.48-0.89, p = 0.006), as were those with T2 tumors (OR0.25 CI0.22-0.29, p < 0.0001). Academic facilities were more likely to resect eligible patients (OR 1.90 CI1.45-2.49, p < 0.0001). Between 2004 and 2013, resection rates more than doubled from 9.1% to 21.7%. Overall, 68.7% of patients were not offered surgery despite having no identifiable contraindication. In patients not receiving surgery, only 7% underwent pathologic mediastinal staging.InterpretationRates of resection are increasing, but two thirds of potentially eligible patients fail to undergo surgery. Further study is required to address the lack of concordance between guidelines and practice.

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