Temporal trends in the management of potentially resectable lung cancer.
BACKGROUND
Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time.


METHODS
This investigation was a cohort study of tumor-registry data linked to Medicare claims.


RESULTS
Between 1992 and 2002, 24,030 patients--mean age 75 +/- 6 years, 55% men--were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97).


CONCLUSIONS
Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.
Farjah
Farhood
F
Surgical Outcomes Research Center, University of Washington, Seattle, Washington, USA.
Wood
Douglas E
DE
Yanez
David
D
Symons
Rebecca G
RG
Krishnadasan
Bahirathan
B
Flum
David R
DR
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data; D015331:Cohort Studies; D003131:Combined Modality Therapy; D015897:Comorbidity; D019317:Evidence-Based Medicine / Q000639:trends*; D005260:Female; D006297:Health Services Accessibility / Q000639:trends; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D016017:Odds Ratio; D011013:Pneumonectomy / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000639:trends*; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D012042:Registries; D012086:Reoperation; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data