title: Prevalence and predictors of neoadjuvant therapy for stage IIIA non-small cell lung cancer in the National Cancer Database: importance of socioeconomic status and treating institution.
abstract: OBJECTIVE
  The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients.
  
  
  METHODS
  Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classified as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively.
  
  
  RESULTS
  The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not.
  
  
  CONCLUSIONS
  Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois. Electronic address: david_sher@rush.edu.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher
authors.affiliation: Department of Cardiothoracic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Liptay
authors.affiliation: Section of Medical Oncology, Rush University Medical Center, Chicago, Illinois.
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Fidler
mesh_terms: D000047:Academies and Institutes / Q000592:standards / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002173:Cancer Care Facilities / Q000145:classification / Q000592:standards / Q000706:statistics & numerical data; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000628:therapy*; D059248:Chemoradiotherapy / Q000706:statistics & numerical data; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D060828:Induction Chemotherapy / Q000706:statistics & numerical data; D016015:Logistic Models; D008175:Lung Neoplasms / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data*; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends; D015995:Prevalence; D012923:Social Class; D014481:United States
chemical_list: D000970:Antineoplastic Agents