ORLANDO, Fla.—Patients diagnosed with Stage T3 non-small-cell lung cancer—even those with affected lymph nodes—appear to gain a significant survival benefit if they undergo resection of the tumor, researchers said here at the Society of Thoracic Surgeons Annual Meeting.
In the poster study, of the patients who underwent surgery, 29.3 percent achieved at least a five-year overall survival compared with just 6.8 percent of patients who did not have surgery, reported Paul Speicher, MD, a general surgery fellow at Duke University School of Medicine.
“Optimal management of patients with T3 lung cancer has not been clearly established by any randomized controlled trial, and it is unlikely such a trial will be attempted. The take-home message here is that the patients who don't get surgery really don't do well. Those who do not get an operation have dismal outcomes. We need to look into ways of getting people to have operations. Regardless of N stage, surgery offers a significant survival benefit.”
He said that currently, treatment recommendations for patients with T3 non-small-cell lung cancer that invades local structures such as the chest wall, proximal airway, or mediastinum is dependent on the nodal status.
In his presentation, he noted that patients who underwent surgery had better outcomes if there were no involved lymph nodes than if there were involved lymph nodes.
After adjustment for variables, the results showed that patients with T3N0 disease who had resection of their cancer had a 61 percent reduced risk of death at five years compared with patients who did not undergo surgery.
If a person was diagnosed with T3N1 disease and had an operation the risk of death at five years was reduced by 47 percent compared with those who did not have surgery. For patients with T3N2 disease who had surgery, the relative risk reduction was 50 percent compared with patients who did not.
Despite the apparent benefit of surgery, the retrospective study, using the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database, indicated a significant decrease in surgical operation for T3 lung cancer between 1988 and 2010. In 1988, 49.8 percent of patients diagnosed with T3 lung cancer underwent surgery in an attempt to resect the cancer, but by 2010 that had fallen to 37.7 percent.
The research team identified 17,378 patients diagnosed with T3 lung cancer. About half the patients—8,597 or 49.5 percent—were diagnosed with T3N0 disease; T3N1 non-small-cell lung cancer was diagnosed in 2,304 patients, 13.3 percent of the total; and T3N2 disease was diagnosed in 6,477 patients, 37.3 percent of the total.
The type of surgery also appeared to impact outcomes, he said. “Lobectomy, compared with sublobar resection or pneumonectomy, offered long-term survival benefit.” The risk of death at five years was 21 percent higher if the surgeon performed a sublobar resection and nine percent higher if the patients had pneumonectomy.
Speicher acknowledged that the use of the SEER database created some limitations, particularly because the database did not routinely capture the functioning capacity of the patients nor comorbidities—both of which could have been influential in determining if a patient was a candidate for surgery.
“Selection bias is likely a factor in this study,” he said. “Nonetheless, multidisciplinary evaluation is warranted in all patients with locally advanced non-small-cell lung cancer given the potential survival benefits.”
The co-moderator of the poster discussion session that included the study, Jonathan D'Cunha, MD, PhD, Associate Director of the Thoracic Surgery Department and Associate Professor of Cardiothoracic Surgery at the University of Pittsburgh School of Medicine, agreed that the retrospective nature of the study could have impacted the results. “Overall, though, the study speaks to surgery for these patients.”
Speicher said that when the researchers scrutinized the database for possible predictors of why individuals were not offered surgery, several significant factors were evident: For every decade older in age a person was at the time of lung cancer presentation, the chance of undergoing surgery was reduced; men were less likely to be given surgery; blacks were less likely to get surgery; and unmarried individuals were also less likely to undergo surgery.
He said that in particular younger individuals and those without nodal involvement should be carefully considered for surgery. “We think our study calls for a multidisciplinary evaluation of patients who may be borderline candidates to see if you can get to that point where they can get an operation and realize the survival benefit.”