Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection.

Objectives: Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections. Methods: The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non-small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed. Results: A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections. Conclusions: High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study.

Intraoperative Versus Preoperative Diagnosis of Lung Cancer: Differences in Treatments and Patient Outcomes.

OBJECTIVES: Non-small cell lung cancer (NSCLC) is frequently diagnosed during surgical resection. It remains unclear if lack of preoperative tissue diagnosis influences likelihood of receipt of guideline-concordant care or postoperative outcomes. METHODS: A retrospective cohort analysis was completed utilizing the National Cancer Database for patients undergoing lung resection with clinical stage 1 NSCLC from 2004 to 2018. Diagnosis during resection was defined as zero days between diagnosis and definitive lung resection. Patients receiving neoadjuvant therapy were excluded. Subgroup analyses were completed by resection type, including wedge resection. RESULTS: The cohort included 91,328 patients, 33,517 diagnosed during definitive resection and 57,811 diagnosed preoperatively. For patients diagnosed preoperatively, median time from diagnosis to surgery was 42 days (interquartile range 28-63 days). Patients diagnosed intraoperatively had smaller median tumor size (1.7 cm vs. 2.5 cm, P < .01) and were more likely to undergo wedge resection (10,668 [31.8%] vs. 7,617 [13.2%], P < .01). Intraoperative diagnosis resulted in lower likelihood of nodal sampling (27,356 [81.9%] vs. 53,183 [92.4%], P < .01) and nodal upstaging (2,482 [9.7%] vs. 7701 [15.5%], P < .01). Amongst patients with intraoperative diagnoses, those treated via wedge resection were less likely to undergo lymph node sampling (5,515 [52.0%] vs. 5,606 [61.1%], P < .01). Amongst patients with positive lymph nodes, patients diagnosed intraoperatively were less likely to receive adjuvant therapy (1,677 [5.0%] vs. 5,669 [9.8%], P < .01). CONCLUSIONS: Preoperative tissue diagnosis of NSCLC is associated with more frequent lymph node harvest, increased rates of upstaging and receipt of adjuvant therapy. Preoperative workup may contribute to increased rates of guideline-concordant lung cancer care.

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non-small cell lung cancer.

OBJECTIVES: Stereotactic body radiation therapy (SBRT) is increasingly used to treat non-small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery. METHODS: Data on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan-Meier log rank test were employed. RESULTS: In total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities. CONCLUSIONS: Differences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Characteristics of High-Volume Lung Segmentectomy Hospitals: A Propensity Score-Matched Analysis.

BACKGROUND: Segmental resection continues to gain favor in the treatment of early-stage non-small cell lung cancer, but there is limited data on outcomes as related to facility volume. The purpose of this study is to better define the relationship between segmentectomy outcomes, survival, and facility volume. METHODS: A retrospective cohort analysis was completed using the National Cancer Database. Patients with stage I disease undergoing segmentectomy 2004 to 2015 were included. Facility volume was determined per year; facilities performing higher than the median number of segmental resections were deemed high-volume and retained that classification for the remainder of the study. Propensity-score matching was used to compare 5-year survival and outcomes. RESULTS: Six hundred eighty-one centers performing 2481 segmentectomies were included. High-volume centers had higher utilization of minimally invasive approaches and lower conversion rates. There was no difference in readmission or 30-day mortality, but 90-day mortality differed between groups (1.2% vs. 2.6%, P = .03). High-volume centers were more likely to sample lymph nodes (88.5% vs. 80.7%, P < .01), and patients were less likely to have positives margins (1.3% vs. 2.7%, P = .03). Patients were no more likely to be upstaged based on facility volume (4.6% vs. 3.3%, P = .21). Overall, 5-year survival was better for patients treated at high-volume centers in the full cohort (69.5% vs. 66.4%, P = .014) but in propensity score-matched analysis this survival difference became non-significant (68.0% vs. 67.9% (P = .172). CONCLUSION: Segmentectomy performed at high-volume centers is associated with more frequent use of minimally invasive approach, more frequent negative margins, and improved 90-day survival.

Race is a Risk Factor for the Deferral of Resection and Radiation for Early-Stage Lung Cancer.

PURPOSE: There remain profound race-related disparities in the treatment of non-small cell lung cancer (NSCLC). Deferral of operative management for early-stage disease is recognized as driver of this disparity. Black race has been associated with higher rates of surgical deferral. It remains unclear how race impacts likelihood of receiving radiation therapy after declining surgical management of NSCLC. PATIENTS AND METHODS: A retrospective cohort analysis was completed using data from the National Cancer Database (NCBD) for patients 18 and over with stage I NSCLC offered surgical resection from 2004 to 2015 (N = 89,462). Multivariable logistic regression identified predictors of surgical deferral and predictors for deferral of radiation after deferral of surgery. Kaplan-Meier survival analysis with log-rank tests and multivariable Cox proportional hazards regressions were performed. RESULTS: 87,293 (97.6%) patients underwent surgery, 2169 (2.4%) deferred. Patients who deferred had 2.1 times higher hazard ratio for mortality, (HR = 2.08, [1.97, 2.29], P < .001). Of those that deferred, 1250 (57.6%) received postdeferral radiation. Compared to White patients, Black patients had OR of 1.82 for deferring both surgery and radiation (aOR: 1.82, [1.31, 2.53], P < .001) and Asian and Pacific Island (API) patients had an OR of 2.67 (aOR: 2.67, [1.27, 4.64], P = .008). Other predictors of deferral of therapy included: Medicare or lack of insurance, and treatment at nonacademic medical centers. CONCLUSION: Insurance status and Black race, and API race are associated with deferring surgical therapy and radiation therapy for NSCLC. These findings are consistent with the large body of work showing worse outcomes for treatment of NSCLC in minority patients.

Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer.

OBJECTIVE: The racial gap in surgical treatment for early-stage non-small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level. PATIENTS AND METHODS: We queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year. RESULTS: In total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings. CONCLUSIONS: Trends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.

Adjuvant chemotherapy for pulmonary sarcomatoid carcinoma: A retrospective analysis of the National Cancer Database.

OBJECTIVES: Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed. METHODS: A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis. RESULTS: We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease. CONCLUSIONS: Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients.