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Improved survival in N2 non-small cell lung cancer: better staging or better treatment; a SEER database retrospective cohort analysis

Year: 2022
Type: article
Study design: Observational Study
Abstract: Background: Over the past several decades, there has been an apparent improvement in survival of patients with stage IIIA-N2 non-small cell lung cancer (NSCLC). Positron emission tomography (PET)-scanning for NSCLC staging/restaging was approved by the Centers of Medicare and Medicaid Services (CMS) in 2001. We sought to determine whether this survival improvement was due to more sensitive staging-modalities and/or an evolution in surgical practice. Methods: The Surveillance, Epidemiology, and End Results Program (SEER) database was queried [1988–2013] to identify patients with N2M0/1-NSCLC. Comparisons were made between two time periods defined by the time PET approval was granted by CMS: period-1 (P1) from 1988–2001 and period-2 (P2) from 2002–2013. Patients treated surgically (1988–2001 vs. 2002–2013) were propensity matched. Results: This study included 224,295 patients with N2-M0/M1 NSCLC. The 5-, 10-year overall survival (OS) was 4.8%, 2.2% in P1 (median OS 6 months, 95% CI: 5.9–6.1 months), and 6.7%, 3.2% in P2 (median OS 6 months, 95% CI: 6–6.1 months). There was a significant increase in the incidence of M1 disease in P2 compared to P1 (63% vs. 55%, P<0.001); 54,070 patients had T0-3N2M0 and their OS was significantly better in P2 (5-year OS rate: 16.3%, median OS: 15 months, 95% CI: 14.8–15.2 months), compared to P1 (5-year OS rate: 11.8%, median OS: 12 months, 95% CI: 11.7–12.3 months) (P<0.001). Survival was significantly better in P2 regardless of treatment modality. In patients undergoing surgical resection, there was a significant increased use of lobectomy (69% vs. 76.5%) and a decreased use of pneumonectomy (19% vs. 10%). Significantly more total lymph nodes were resected in P2 vs. P1 (9 vs. 7, P<0.001). In the matched cohorts, 5-year OS was significantly improved in P2 (5-year OS rate: 34%, median OS: 34 months, 95% CI: 31.7–36.3 months) compared to P1 (5-year OS rate: 24%, median OS: 23 months, 95% CI: 21.7–24.3 months) (P<0.001). Conclusions: The main driver of the significant improvement in survival of cT0-3N2M0-NSCLC patients over the last 25 years was improved clinical-staging with increased PET utilization. Survival-improvements might also be credited to surgical-practices evolution.
DOI: 10.21037/vats-22-25
Language: English
Field: Medicine
Open Access status: diamond
OpenAlex ID: W4312049166
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