title: Comparative effectiveness of 5 treatment strategies for early-stage non-small cell lung cancer in the elderly.
abstract: OBJECTIVE
  The incidence of early-stage non-small cell lung cancer (NSCLC) among older adults is expected to increase because of demographic trends and computed tomography-based screening; yet, optimal treatment in the elderly remains controversial. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort spanning 2001-2007, we compared survival outcomes associated with 5 strategies used in contemporary practice: lobectomy, sublobar resection, conventional radiation therapy, stereotactic ablative radiation therapy (SABR), and observation.
  
  
  METHODS
  Treatment strategy and covariates were determined in 10,923 patients aged ≥ 66 years with stage IA-IB NSCLC. Cox regression, adjusted for patient and tumor factors, compared overall and disease-specific survival for the 5 strategies. In a second exploratory analysis, propensity-score matching was used for comparison of SABR with other options.
  
  
  RESULTS
  The median age was 75 years, and 29% had moderate to severe comorbidities. Treatment distribution was lobectomy (59%), sublobar resection (11.7%), conventional radiation (14.8%), observation (12.6%), and SABR (1.1%). In Cox regression analysis with a median follow-up time of 3.2 years, SABR was associated with the lowest risk of death within 6 months of diagnosis (hazard ratio [HR] 0.48; 95% confidence interval [CI] 0.38-0.63; referent is lobectomy). After 6 months, lobectomy was associated with the best overall and disease-specific survival. In the propensity-score matched analysis, survival after SABR was similar to that after lobectomy (HR 0.71; 95% CI 0.45-1.12; referent is SABR). Conventional radiation and observation were associated with poor outcomes in all analyses.
  
  
  CONCLUSIONS
  In this population-based experience, lobectomy was associated with the best long-term outcomes in fit elderly patients with early-stage NSCLC. Exploratory analysis of SABR early adopters suggests efficacy comparable with that of surgery in select populations. Evaluation of these therapies in randomized trials is urgently needed.
authors.affiliation: Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Shervin M
authors.initials: SM
authors.lastname: Shirvani
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.forename: Joe Y
authors.initials: JY
authors.lastname: Chang
authors.forename: James W
authors.initials: JW
authors.lastname: Welsh
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Gomez
authors.forename: Stephen
authors.initials: S
authors.lastname: Swisher
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D005260:Female; D006801:Humans; D008168:Lung / Q000601:surgery; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D008297:Male; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000379:methods / Q000401:mortality; D016016:Proportional Hazards Models; D016634:Radiosurgery / Q000379:methods / Q000401:mortality; D011878:Radiotherapy / Q000379:methods / Q000401:mortality; D012307:Risk Factors; D018426:SEER Program; D012907:Smoking / Q000401:mortality; D016019:Survival Analysis; D016896:Treatment Outcome; D057832:Watchful Waiting