title: Neoadjuvant chemoradiation and surgery improves survival outcomes compared with definitive chemoradiation in the treatment of stage IIIA N2 non-small-cell lung cancer.
abstract: OBJECTIVE
  The objective of this study was to compare survival in patients with stage IIIA (N2) non-small-cell lung cancer (NSCLC) treated with definitive chemoradiation (CRT) or surgery plus neoadjuvant chemoradiation or chemotherapy (CRTS).
  
  
  METHODS
  A retrospective analysis of 242 patients with stage IIIA (N2) NSCLC treated with curative intent between 1997 and 2007, identified 215 patients with surgically resectable disease. Overall survival outcomes were analysed using the Kaplan-Meier plots, log-rank tests and Cox proportional hazards models adjusting for age, gender, histology, smoking history and performance status. Recurrences were compared using competing risks methods, including the proportional subdistribution hazards regression model.
  
  
  RESULTS
  CRTS was used to treat 104 patients and CRT in 111. Comparing CRTS with CRT patients, median age was 60 vs 62, 50 (48%) vs 69 (62%) were male and 65 (62.5%) vs 60 (54%) had adenocarcinoma. Of CRTS patients, 83 (80%) had a lobectomy. CRTS patients compared with CRT patients had decreased risk of recurrence at any site [hazard ratio (HR) = 0. 46, 95% confidence interval (CI): 0.32-0.64 P < 0.0001], local recurrence (HR = 0.50, 95% CI: 0.29-0.87, P = 0.013), loco--regional recurrence (HR = 0.51, 95% CI: 0.33-0.78, P = 0.002) and death (HR: 0.45, 95% CI: 0.33-0.62, P < 0.0001) with a median survival of 4.2 years vs 1.7 years). Risk of distant recurrence was also reduced in the surgical group (HR: 0.57; 95% CI: 0.38-0.87, P = 0.017). Treatment-related mortality was low in both cohorts.
  
  
  CONCLUSIONS
  For patients with surgically resectable stage IIIA (N2) NSCLC, neoadjuvant therapy plus surgery reduces loco-regional and distant recurrence and improves survival. Treatment-related mortality was not significantly increased compared with the patients treated with CRT alone.
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada gail.darling@uhn.ca.
authors.forename: Gail E
authors.initials: GE
authors.lastname: Darling
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Fei
authors.initials: F
authors.lastname: Li
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Demetris
authors.initials: D
authors.lastname: Patsios
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Christine
authors.initials: C
authors.lastname: Massey
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Adam G
authors.initials: AG
authors.lastname: Wallis
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Linda
authors.initials: L
authors.lastname: Coate
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Shaf
authors.initials: S
authors.lastname: Keshavjee
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Pierre
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: De Perrot
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Yasufuku
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Cypel
authors.affiliation: Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
authors.forename: Tom
authors.initials: T
authors.lastname: Waddell
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000453:epidemiology / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D059248:Chemoradiotherapy / Q000401:mortality*; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000401:mortality*; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Chemoradiation; Non-small-cell lung cancer; Stage IIIA; Surgery; Survival