title: Predictors and outcomes of limited resection for early-stage non-small cell lung cancer.
abstract: BACKGROUND
  Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections.
  
  
  METHODS
  A population- and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests.
  
  
  RESULTS
  One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P = .02), non-fee-for-service compensation (P = .008), and National Cancer Institute cancer center designation (P = .006) were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P = .003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI = -.1% to 9.2%, P = .09). Postoperative complications did not differ by type of surgery (all P > .05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P = .05).
  
  
  CONCLUSIONS
  Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection.
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. sbillmeier@partners.org
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Billmeier
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.forename: Alan M
authors.initials: AM
authors.lastname: Zaslavsky
authors.forename: David R
authors.initials: DR
authors.lastname: Nerenz
authors.forename: Michael T
authors.initials: MT
authors.lastname: Jaklitsch
authors.forename: Selwyn O
authors.initials: SO
authors.lastname: Rogers
mesh_terms: D000328:Adult; D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D018588:Fee-for-Service Plans; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured; D006278:Medicare; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D011013:Pneumonectomy / Q000191:economics / Q000379:methods*; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States