title: Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer.
abstract: BACKGROUND
  Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery.
  
  
  METHODS
  A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fisher's exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn.
  
  
  RESULTS
  In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001).
  
  
  CONCLUSIONS
  Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia. Electronic address: msanch2@emory.edu.
authors.forename: Manu S
authors.initials: MS
authors.lastname: Sancheti
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: John N
authors.initials: JN
authors.lastname: Melvan
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Medbery
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Fernandez
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Theresa W
authors.initials: TW
authors.lastname: Gillespie
authors.affiliation: Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Qunna
authors.initials: Q
authors.lastname: Li
authors.affiliation: Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Jose N
authors.initials: JN
authors.lastname: Binongo
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Allan
authors.initials: A
authors.lastname: Pickens
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome