title: The National Surgical Quality Improvement Program risk calculator does not adequately stratify risk for patients with clinical stage I non-small cell lung cancer.
abstract: OBJECTIVE
  The study objective was to validate the National Surgical Quality Improvement Program (NSQIP) Risk Calculator in stratifying risk estimates for patients who received surgery or stereotactic body radiation therapy for clinical stage I non-small cell lung cancer.
  
  
  METHODS
  A retrospective analysis of patients with clinical stage I non-small cell lung cancer undergoing surgery (N = 279) or stereotactic body radiation therapy (N = 206) from 2009 to 2012 was performed. NSQIP complication risk estimates were calculated for both surgical and stereotactic body radiation therapy cases using the NSQIP Surgical Risk Calculator. NSQIP complication risk estimates were compared as continuous variables and by quartile ranges.
  
  
  RESULTS
  Compared with patients undergoing video-assisted thoracoscopic surgery wedge resection, patients receiving stereotactic body radiation therapy were older, had larger tumors, had lower forced expiratory volume (FEV1) in 1 second and diffusing capacity of the lungs (DLCO) for carbon monoxide values, had higher American Society of Anesthesiologists scores, had higher rates of dyspnea, and had higher NSQIP serious complication risk estimates (all P < .05). Compared with patients undergoing video-assisted thoracoscopic surgery lobectomy, patients receiving stereotactic body radiation therapy had similar disparities, along with higher Adult Comorbidity Evaluation-27 (ACE) scores comorbidity scores, higher rates of cardiac comorbidities, and worse functional status (all P < .05). Variables associated with receiving stereotactic body radiation therapy treatment, rather than wedge resection, included increasing age, higher Adult Comorbidity Evaluation (ACE)-27 comorbidity score, dyspnea status, and decreasing FEV1 in 1 second and DLCO for carbon monoxide, but NSQIP serious complication risk score. In addition, surgical patients' actual serious complication rate (16.6% vs 8.8%) and pneumonia rate (6.0% vs 3.2%) were significantly higher than the NSQIP risk calculator predicted (all P < .05).
  
  
  CONCLUSIONS
  The National Surgical Quality Improvement Program risk calculator does not effectively classify or stratify risk in patients with stage I non-small cell lung cancer. Continued efforts are needed to assess risk in this population and develop more tailored treatment decision aids.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: Pamela
authors.initials: P
authors.lastname: Samson
authors.affiliation: Department of Radiation Oncology, Washington University in St Louis, Mo.
authors.forename: Clifford G
authors.initials: CG
authors.lastname: Robinson
authors.affiliation: Department of Radiation Oncology, Washington University in St Louis, Mo.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Bradley
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: Audrey
authors.initials: A
authors.lastname: Lee
authors.affiliation: Division of Cardiothoracic Surgery, St Luke's Hospital in Chesterfield, Mo.
authors.forename: Stephen
authors.initials: S
authors.lastname: Broderick
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: A Sasha
authors.initials: AS
authors.lastname: Krupnick
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
authors.forename: Bryan F
authors.initials: BF
authors.lastname: Meyers
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St Louis, Mo. Electronic address: crabtreet@wustl.edu.
authors.forename: Traves
authors.initials: T
authors.lastname: Crabtree
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D015897:Comorbidity; D016208:Databases, Factual; D003661:Decision Support Techniques; D005260:Female; D005541:Forced Expiratory Volume; D006304:Health Status; D006801:Humans; D008168:Lung / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000009:adverse effects / Q000401:mortality; D011183:Postoperative Complications / Q000209:etiology; D011237:Predictive Value of Tests; D011653:Pulmonary Diffusing Capacity; D016634:Radiosurgery / Q000009:adverse effects / Q000401:mortality; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000401:mortality; D016896:Treatment Outcome
keywords: NSQIP; SBRT; lobectomy; lung cancer