title: Trends in the operative management and outcomes of T4 lung cancer.
abstract: BACKGROUND
  This study describes temporal trends and variables in the operative management and outcomes of patients with T4 lung tumors in the general community.
  
  
  METHODS
  Surveillance, Epidemiology, and End-Results-Medicare data were used for a cohort study (1992 to 2002) of patients with stage IIIB lung cancer defined by T4 tumors. Patient characteristics, tumor size, nodal status, use of staging modalities, extent of resection, multi-modality therapy, and provider volume were examined. Follow-up death data were available through 2005.
  
  
  RESULTS
  Among 13,077 cases of T4 lung tumors, 1177 patients (9%) underwent resection. Over time, use of mediastinoscopy (20%) did not change (p = 0.49); mediastinal lymphadenectomy increased from 10% to 29% (p < 0.001) and neoadjuvant therapy from 4% to 8% (p = 0.04). Five-year survival rates increased from 15% to 35% (p < 0.001). A higher hazard of death was associated with increasing age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00 to 1.03), comorbidity index of 3 vs 0 (HR, 1.66; 95% CI 1.24 to 2.21), tumor size 3 cm or more (HR, 1.55; 95% CI, 1.30 to 1.84), N2/N3 nodes (HR, 1.67; 95% CI, 1.40 to 1.98), and sublobar resection (HR, 1.55; 95% CI, 1.26 to 1.90). Mediastinal lymphadenectomy had a significantly lower hazard of death (HR, 0.78; 95% CI, 0.64 to 0.95). Improvements in overall survival over time persisted after adjustment for these factors (p = 0.007).
  
  
  CONCLUSIONS
  Temporal changes in the operative management of T4 tumors coincided with improvements in long-term survival. Our findings corroborate prior work and practice guidelines supporting operative therapy for select patients with T4 lung cancer.
authors.affiliation: Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington 98195-6310, USA.
authors.forename: Farhood
authors.initials: F
authors.lastname: Farjah
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Wood
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Varghese
authors.forename: Rebecca Gaston
authors.initials: RG
authors.lastname: Symons
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality* / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D003131:Combined Modality Therapy; D015897:Comorbidity; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D008197:Lymph Node Excision; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D016017:Odds Ratio; D012189:Retrospective Studies; D018426:SEER Program; D016019:Survival Analysis; D019616:Thoracic Surgical Procedures / Q000639:trends*; D014481:United States / Q000453:epidemiology