title: Pulmonologist involvement, stage-specific treatment, and survival in adults with non-small cell lung cancer and chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Up to 80% of patients with lung cancer have comorbid chronic obstructive pulmonary disease (COPD). Many of them are poor candidates for stage-specific lung cancer treatment due to diminished lung function and poor functional status, and many forego treatment. The negative effect of COPD may be moderated by pulmonologist-guided management.
  
  
  OBJECTIVE
  This study examined the association between pulmonologist management and the probability of receiving the recommended stage-specific treatment modality and overall survival among patients with non-small cell lung cancer (NSCLC) with preexisting COPD.
  
  
  METHODS
  Early- and advanced-stage NSCLC cases diagnosed between 2002 and 2005 with a prior COPD diagnosis (3-24 months before NSCLC diagnosis) were identified in Surveillance, Epidemiology, and End Results tumor registry data linked to Medicare claims. Study outcomes included receipt of recommended stage-specific treatment (surgical resection for early-stage NSCLC and chemotherapy for advanced-stage NSCLC [advNSCLC]) and overall survival. Pulmonologist management was considered present if one or more Evaluation and Management visit claims with pulmonologist specialty were observed within 6 months after NSCLC diagnosis. Stage-specific multivariate logistic regression tested association between pulmonologist management and treatment received. Cox proportional hazard models examined the independent association between pulmonologist care and mortality. Two-stage residual inclusion instrumental variable (2SRI-IV) analyses tested and adjusted for potential confounding based on unobserved factors or measurement error.
  
  
  RESULTS
  The cohorts included 5,488 patients with early-stage NSCLC and 6,426 patients with advNSCLC disease with preexisting COPD. Pulmonologist management was recorded for 54.9% of patients with early stage NSCLC and 35.7% of patients with advNSCLC. Of those patients with pulmonologist involvement, 58.5% of patients with early NSCLC received surgical resection, and 43.6% of patients with advNSCLC received chemotherapy. Pulmonologist management post NSCLC diagnosis was associated with increased surgical resection rates (odds ratio, 1.26; 95% confidence interval, 1.11-1.45) for early NSCLC and increased chemotherapy rates (odds ratio, 1.88; 95% confidence interval, 1.67-2.10) for advNSCLC. Pulmonologist management was also associated with reduced mortality risk for patients with early-stage NSCLC but not AdvNSCLC.
  
  
  CONCLUSIONS
  Pulmonologist management had a positive association with rates of stage-specific treatment in both groups and overall survival in early-stage NSCLC. These results provide preliminary support for the recently published guidelines emphasizing the role of pulmonologists in lung cancer management.
authors.affiliation: 1 Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Janaki A
authors.initials: JA
authors.lastname: Deepak
authors.forename: Xinyi
authors.initials: X
authors.lastname: Ng
authors.forename: Josephine
authors.initials: J
authors.lastname: Feliciano
authors.forename: Li
authors.initials: L
authors.lastname: Mao
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Davidoff
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D002983:Clinical Competence; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008297:Male; D009367:Neoplasm Staging; D016017:Odds Ratio; D016016:Proportional Hazards Models; D029424:Pulmonary Disease, Chronic Obstructive / Q000401:mortality / Q000628:therapy*; D015272:Pulmonary Medicine; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D000078329:Workforce
keywords: chronic obstructive pulmonary disease; non–small cell lung carcinoma; pulmonology medicine; survival