title: Lobectomy, sublobar resection, and stereotactic ablative radiotherapy for early-stage non-small cell lung cancers in the elderly.
abstract: OBJECTIVE
  The incidence of early-stage non-small cell lung cancer (NSCLC) among the elderly is expected to rise dramatically owing to demographic trends and increased computed tomographic screening. However, to our knowledge, no modern trials have compared the most common treatments for NSCLC.
  
  
  OBJECTIVE
  To determine clinical characteristics and survival outcomes associated with the 3 most commonly used definitive therapies for early-stage NSCLC in the elderly.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results database linked to Medicare was used to determine the baseline characteristics and outcomes of 9093 patients with early-stage, node-negative NSCLC who underwent definitive treatment consisting of lobectomy, sublobar resection, or stereotactic ablative radiotherapy (SABR) from January 1, 2003, through December 31, 2009.
  
  
  METHODS
  Overall and lung cancer-specific survival were compared using Medicare claims through December 31, 2012. We used proportional hazards regression and propensity score matching to adjust outcomes for key patient, tumor, and practice environment factors.
  
  
  RESULTS
  The median age was 75 years, and treatment distribution was 79.3% for lobectomy, 16.5% for sublobar resection, and 4.2% for SABR. Unadjusted 90-day mortality was highest for lobectomy (4.0%) followed by sublobar resection (3.7%; P = .79) and SABR (1.3%; P = .008). At 3 years, unadjusted mortality was lowest for lobectomy (25.0%), followed by sublobar resection (35.3%; P < .001) and SABR (45.1%; P < .001). Proportional hazards regression demonstrated that sublobar resection was associated with worse overall survival (adjusted hazard ratio [AHR], 1.32 [95% CI, 1.20-1.44]; P < .001) and lung cancer-specific survival (AHR, 1.50 [95% CI, 1.29-1.75]; P < .001) compared with lobectomy. Propensity score-matching analysis reiterated these findings for overall survival (AHR, 1.36 [95% CI, 1.17-1.58]; P < .001) and lung cancer-specific survival (AHR, 1.46 [95% CI, 1.13-1.90]; P = .004). In proportional hazards regression, SABR was associated with better overall survival than lobectomy in the first 6 months after diagnosis (AHR, 0.45 [95% CI, 0.27-0.75]; P < .001) but worse survival thereafter (AHR, 1.66 [95% CI, 1.39-1.99]; P < .001). Propensity score-matching analysis of well-matched SABR and lobectomy cohorts demonstrated similar overall survival in both groups (AHR, 1.01 [95% CI, 0.74-1.38]; P = .94).
  
  
  CONCLUSIONS
  Lobectomy was associated with better outcomes than sublobar resection in elderly patients with early-stage NSCLC. Propensity score matching suggests that SABR may be a good option among patients with very advanced age and multiple comorbidities.
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston2Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona.
authors.forename: Shervin M
authors.initials: SM
authors.lastname: Shirvani
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Joe Y
authors.initials: JY
authors.lastname: Chang
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: James
authors.initials: J
authors.lastname: Welsh
authors.affiliation: Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona.
authors.forename: Anna
authors.initials: A
authors.lastname: Likhacheva
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008175:Lung Neoplasms / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000379:methods*; D016634:Radiosurgery / Q000379:methods*; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D015996:Survival Rate / Q000639:trends; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology