Analysis of Delayed Surgical Treatment and Oncologic Outcomes in Clinical Stage I Non-Small Cell Lung Cancer.
Analysis of Delayed Surgical Treatment and Oncologic Outcomes in Clinical Stage I Non-Small Cell Lung Cancer.
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DOI：
10.1001/jamanetworkopen.2021.11613
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发表时间：
2021-05-03
影响因子：
13.8
通讯作者：
Puri V
中科院分区：
文献类型：
--
作者：
Heiden BT;Eaton DB Jr;Engelhardt KE;Chang SH;Yan Y;Patel MR;Kreisel D;Nava RG;Meyers BF;Kozower BD;Puri V
这项队列研究探讨了在退伍军人健康管理局系统治疗的一组非小细胞肺癌患者中，延迟手术治疗与复发和生存之间的关系。非小细胞肺癌（NSCLC）患者延迟手术治疗与肿瘤学结局之间的关系是什么？在这项使用退伍军人健康管理局数据的9904例临床I期NSCLC患者的回顾性队列研究中，从放射学诊断日期延迟超过12周的手术与复发风险增加和总生存率降低相关。这些结果表明，临床I期NSCLC患者应在影像学诊断后至少12周内接受手术治疗。由于先前的研究对癌症诊断日期的定义不精确，因此对非小细胞肺癌（NSCLC）患者延迟手术治疗与肿瘤学结局之间的关系了解甚少。使用统一的方法来量化手术治疗延迟，并检查其与几种肿瘤结局的相关性。这项回顾性队列研究使用退伍军人健康管理局（VHA）系统的新数据集进行。纳入的患者患有临床I期NSCLC，并于2006年至2016年在VHA系统内接受切除术。手术治疗时间（TTS）定义为术前诊断性计算机断层扫描成像和手术治疗之间的时间。我们使用限制性三次样条函数评估TTS和几种延迟相关结果之间的关联。数据分析于二零二一年十一月进行。癌症诊断和手术治疗之间的等待时间（即TTS）。评估了几种延迟相关的肿瘤学结局，包括病理分期上调、切缘阳性的切除和复发。我们还评估了总体生存率。在9904例接受手术治疗的临床I期NSCLC患者中，9539例（96.3%）为男性，4972例（50.5%）目前吸烟，平均（SD）年龄为67.7（7.9）岁。平均（SD）TTS为70.1（38.6）天。TTS与病理分期升高或切缘阳性的风险增加无关。在4158例患者（42.0%）中检测到复发，中位（四分位距）随访时间为6.15（2.51-11.51）年。与复发风险增加相关的因素包括年龄较小（年龄每增加1岁的风险比[HR]，0.992; 95% CI，0.987-0.997; P = .003），Charlson合并症指数评分较高（复合评分每增加1个单位的HR，1.055; 95% CI，1.037-1.073; P < .001），肺段切除术（HR vs肺叶切除术，1.352; 95% CI，1.179-1.551; P < .001）或楔形切除术（HR vs肺叶切除术，1.282; 95% CI，1.179-1.394; P <0.001），肿瘤尺寸较大（例如，31-40 mm vs <10 mm; HR，1.209; 95% CI，1.051-1.390; P = .008），肿瘤分级较高（例如，II vs I; HR，1.210; 95% CI，1.085-1.349; P < .001），检查的淋巴结数量较少（例如≥10 vs <10; HR，0.866; 95%CI，0.803-0.933; P < .001），较高的病理分期（III vs I; HR，1.571; 95%CI，1.351-1.837; P < .001），以及较长的TTS，12周后风险增加。对于手术延迟超过12周的每一周，复发风险增加0.4%（HR，1.004; 95% CI，1.001-1.006; P = .002）。与延迟手术治疗相关的因素包括非裔美国人种族（比值比[OR] vs白色人种，1.267; 95% CI，1.112-1.444; P < .001），区域剥夺指数[ADI]评分较高（ADI评分每增加1个单位的OR，1.005; 95% CI，1.002-1.007; P = .002），医院病例负荷较低（病例负荷每增加1个单位的OR，0.998; 95% CI，0.998-0.999; P = .001）和诊断年份，近期手术更可能延迟（每增加一年的OR为0.900; 95%CI为0.884-0.915; P <0.001）。在确诊后12周内接受手术治疗的患者的总体生存率明显高于延迟12周以上接受手术治疗的患者（HR，1.132; 95% CI，1.064-1.204; P < .001）。使用更精确的TTS定义，这项研究发现手术延迟超过12周与复发风险增加和生存率降低相关。这些结果表明，临床I期NSCLC患者应在该时间范围内接受快速治疗。
This cohort study examines the association between delayed surgical treatment and recurrence and survival among patients with non–small cell lung cancer in a cohort of patients treated in the Veterans Health Administration system. What is the association between delayed surgical treatment and oncologic outcomes among patients with non–small cell lung cancer (NSCLC)? In this retrospective cohort study of 9904 patients with clinical stage I NSCLC using data from the Veterans Health Administration, surgical procedures that were delayed more than 12 weeks from the date of radiographic diagnosis were associated with increased risk of recurrence and worse overall survival. These findings suggest that patients with clinical stage I NSCLC should receive surgical treatment within at least 12 weeks of radiographic diagnosis. The association between delayed surgical treatment and oncologic outcomes in patients with non–small cell lung cancer (NSCLC) is poorly understood given that prior studies have used imprecise definitions for the date of cancer diagnosis. To use a uniform method to quantify surgical treatment delay and to examine its association with several oncologic outcomes. This retrospective cohort study was conducted using a novel data set from the Veterans Health Administration (VHA) system. Included patients had clinical stage I NSCLC and were undergoing resection from 2006 to 2016 within the VHA system. Time to surgical treatment (TTS) was defined as the time between preoperative diagnostic computed tomography imaging and surgical treatment. We evaluated the association between TTS and several delay-associated outcomes using restricted cubic spline functions. Data analyses were performed in November 2021. Wait time between cancer diagnosis and surgical treatment (ie, TTS). Several delay-associated oncologic outcomes, including pathologic upstaging, resection with positive margins, and recurrence, were assessed. We also assessed overall survival. Among 9904 patients who underwent surgical treatment for clinical stage I NSCLC, 9539 (96.3%) were men, 4972 individuals (50.5%) were currently smoking, and the mean (SD) age was 67.7 (7.9) years. The mean (SD) TTS was 70.1 (38.6) days. TTS was not associated with increased risk of pathologic upstaging or positive margins. Recurrence was detected in 4158 patients (42.0%) with median (interquartile range) follow-up of 6.15 (2.51-11.51) years. Factors associated with increased risk of recurrence included younger age (hazard ratio [HR] for every 1-year increase in age, 0.992; 95% CI, 0.987-0.997; P = .003), higher Charlson Comorbidity Index score (HR for every 1-unit increase in composite score, 1.055; 95% CI, 1.037-1.073; P < .001), segmentectomy (HR vs lobectomy, 1.352; 95% CI, 1.179-1.551; P < .001) or wedge resection (HR vs lobectomy, 1.282; 95% CI, 1.179-1.394; P < .001), larger tumor size (eg, 31-40 mm vs <10 mm; HR, 1.209; 95% CI, 1.051-1.390; P = .008), higher tumor grade (eg, II vs I; HR, 1.210; 95% CI, 1.085-1.349; P < .001), lower number of lymph nodes examined (eg, ≥10 vs <10; HR, 0.866; 95% CI, 0.803-0.933; P < .001), higher pathologic stage (III vs I; HR, 1.571; 95% CI, 1.351-1.837; P < .001), and longer TTS, with increasing risk after 12 weeks. For each week of surgical delay beyond 12 weeks, the hazard for recurrence increased by 0.4% (HR, 1.004; 95% CI, 1.001-1.006; P = .002). Factors associated with delayed surgical treatment included African American race (odds ratio [OR] vs White race, 1.267; 95% CI, 1.112-1.444; P < .001), higher area deprivation index [ADI] score (OR for every 1 unit increase in ADI score, 1.005; 95% CI, 1.002-1.007; P = .002), lower hospital case load (OR for every 1-unit increase in case load, 0.998; 95% CI, 0.998-0.999; P = .001), and year of diagnosis, with less recent procedures more likely to have delay (OR for each additional year, 0.900; 95% CI, 0.884-0.915; P < .001). Patients with surgical treatment within 12 weeks of diagnosis had significantly better overall survival than those with procedures delayed more than 12 weeks (HR, 1.132; 95% CI, 1.064-1.204; P < .001). Using a more precise definition for TTS, this study found that surgical procedures delayed more than 12 weeks were associated with increased risk of recurrence and worse survival. These findings suggest that patients with clinical stage I NSCLC should undergo expeditious treatment within that time frame.
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