Search

ObjectiveThis qualitative study sought to uncover factors that influence decisions to offer curative-intent surgery for patients with advanced-stage (stage IIIB/IV) non-small cell lung cancer.MethodsA trained interviewer conducted open-ended, semistructured telephone interviews with cardiothoracic surgeons in the United States. Participants were recruited from the Thoracic Surgery Outcomes Research Network, with subsequent diversification through snowball sampling. Four hypothetical clinical scenarios were presented, each demonstrating varying levels of ambiguity with respect to international guideline recommendations. Interviews continued until thematic saturation was reached. Interview transcripts were coded using inductive reasoning and conventional content analysis.ResultsOf the 27 participants, most had been in practice for ≤20 years (n = 23) and were in academic practice (n = 18). When considering nonguideline-concordant surgeries, participants were aware of relevant guidelines but acknowledged their limitations for unique scenarios. Surgeons perceived that a common barrier to offering surgery is incomplete nonsurgeon physician understanding of surgical capabilities or expected morbidity; and that improved education is necessary to correct these misperceptions. Surgeons expressed concern that undertaking a controversial resection for an individual patient could fracture trust built in long-term professional relationships. Surgeons may face pressure from patients to operate despite a low expectation of clinical benefit, leading to emotional turmoil for the patient and surgeon.ConclusionsThis qualitative study generates the hypothesis that the scope of current guidelines, availability of clinical trial protocols, perceived surgical knowledge among nonsurgeon colleagues, interprofessional relationships, and emotional pressure all influence a surgeon's willingness to offer curative-intent surgery for patients with advanced-stage non-small cell lung cancer.

Open in new tab Download slide OBJECTIVES Visceral pleural invasion (VPI) guidelines, for tumours ≤4 cm are ambiguous. Non-small-cell lung cancers (NSCLCs) 3 to ≤4 cm are assigned the T2a designation. Similarly, any tumours with VPI, smaller than 3 cm, are upstaged and also assigned the same T2a designation. We hypothesized that adjuvant chemotherapy would significantly improve 5-year survival for NSCLC ≤4 cm with VPI. METHODS The National Cancer Database was queried from 2010 to 2016 for cases of NSCLC with clinical stage I disease, ≤4 cm, who subsequently underwent surgical resection. These stage I NSCLCs were stratified according to clinical tumour sizes (0 to ≤1, 1 to ≤2, 2 to ≤3 and 3 to ≤4 cm). This cohort was then divided into groups with and without VPI and further split based on the administration of adjuvant chemotherapy. Kaplan–Meier analysis was used to calculate 5-year overall survival (OS) for patients categorized by tumour size, VPI status, and receipt of adjuvant chemotherapy. Multivariable Cox regression adjusting for tumour size and VPI status was used to determine associations between use of adjuvant chemotherapy and OS. RESULTS A total of 61 454 patients with NSCLC and clinical tumour sizes <4 cm were identified and grouped based on size along with VPI and adjuvant chemotherapy. The 5-year OS for combined tumour sizes without VPI was higher than for patients with VPI (66.2% vs 59.5%, P < 0.001). The OS for tumour size (0 to ≤1, 1 to ≤2, 2 to ≤3 and 3 to ≤4 cm) was lower for patients with VPI regardless of size (all P ≤ 0.010). When all tumour sizes were combined, patients with VPI who received adjuvant chemotherapy had an improved 5-year OS compared to patients without adjuvant chemotherapy (65.5% vs 58.8%, P < 0.001). When cohorts were created by tumour size, only VPI tumours 3 to ≤4 cm had a statistically significant increase in 5-year OS for patients receiving adjuvant chemotherapy (68.8% vs 49.9%, P < 0.001). On multivariable Cox regression for OS, adjuvant chemotherapy was associated with significantly longer 5-year OS in tumour size 3 to ≤4 (hazard ratio = 0.62, 95% confidence interval 0.46–0.83, P = 0.001). CONCLUSIONS VPI remains a poor prognostic factor in clinically node-negative, T2a or less, NSCLC patients. Guidelines recommend considering chemotherapy for high-risk T2aN0, margin-negative patients—including those patients with VPI. Based on the analysis, adjuvant chemotherapy should be considered specifically for 3 to ≤4 cm with VPI due to an observed 5-year OS advantage. [ABSTRACT FROM AUTHOR]

Introduction: Signet ring cell (SRC) histology is considered a poor prognostic factor in various cancers. However, primary SRC lung adenocarcinoma is rare and poorly understood. Methods: The National Cancer Database was queried to identify treatment-naïve patients who received lobectomy for primary SRC or non-SRC pT1-2N0 lung adenocarcinoma <4 cm within four months of diagnosis. SRC lung adenocarcinoma was defined by ICD-O-3 code 8490, while non-SRC lung adenocarcinoma was defined by ICD-O-3 codes 8140, 8141, 8143, 8147, 8255, 8260, 8310, 8481, 8560, and 8570–8574. The Kaplan-Meier curve and log-rank test was used to compare five-year OS between SRC versus non-SRC lung adenocarcinoma cohorts. The impact of SRC histology on risk of death was assessed using the Cox proportional hazards regression model. Results: 48,399 patients were included in this study: 62 with primary SRC lung adenocarcinoma and 48,337 with non-SRC lung adenocarcinoma. The mean age of the overall cohort was 67.0 ± 9.6 years. Five-year OS following lobectomy did not differ significantly between SRC lung adenocarcinoma and non-SRC lung adenocarcinoma cohorts (SRC 73.9% vs. non-SRC 69.3%, p = 0.64). SRC histology did not significantly impact risk of death within five years after lobectomy (HR 0.89, p = 0.66). Conclusions: Following lobectomy for pT1-2N0 tumors <4 cm, patients with primary SRC lung adenocarcinoma do not experience worse five-year OS or increased risk of death within five years relative to those with non-SRC lung adenocarcinoma. Additional study, including exploration of emerging molecular profiling data, may serve to better define optimal treatment for this histopathologic group of lung adenocarcinomas. [ABSTRACT FROM AUTHOR]