The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

Ibrahim Azar; Adam Austin; Biplab K Saha; Seongho Kim; Hyejeong Jang; Ali Al Sbihi; Samer Alkassis; Omid Yazpandanah; Jie Chi; Vikram Dhillon; Hiren J Mehta; Amit Chopra; Kristoffer Neu; Syed Arzoo Mehdi; Hirva Mamdani

doi:10.1016/j.cllc.2023.04.002

The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

Clin Lung Cancer. 2023 Jul;24(5):e179-e186. doi: 10.1016/j.cllc.2023.04.002. Epub 2023 Apr 15.

Authors

Affiliations

¹ Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI. Electronic address: Ibrahim_azar@outlook.com.
² Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL.
³ Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI.
⁴ Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY.
⁵ Division of Pulmonary and Critical Care Medicine, Albany Stratton Veterans Affairs' Medical Center, Albany, NY.

PMID: 37217388
DOI: 10.1016/j.cllc.2023.04.002

Abstract

Background: Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.

Methods: Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.

Results: Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.

Conclusions: Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.

Keywords: Cancer Staging; Cancer Treatment; Oncology; Thoracic Malignancy; Veterans.

MeSH terms

Chemoradiotherapy
Combined Modality Therapy
Humans
Lung Neoplasms* / surgery
Neoplasm Staging
Small Cell Lung Carcinoma* / surgery