title: Patterns of care in hilar node-positive (N1) non-small cell lung cancer: A missed treatment opportunity?
abstract: BACKGROUND
  For patients with non-small cell lung cancer (NSCLC) metastatic to hilar lymph nodes (N1), guidelines recommend surgery and adjuvant chemotherapy in operable patients and chemoradiation (CRT) for those deemed inoperable. It is unclear how these recommendations are applied nationally, however.
  
  
  METHODS
  The National Cancer Database was queried to identify patients with a tumor <7 cm (T1/T2) with clinically positive N1 nodes. Patients undergoing CRT (comprising chemotherapy and radiation >45 Gy) or surgical resection were considered adequately treated. Remaining patients were classified as receiving inadequate or no treatment.
  
  
  RESULTS
  Of the 20,366 patients who met the study criteria, 63% underwent adequate treatment (48% surgical resection, 15% CRT). The remainder received inadequate treatment (23%) or no treatment (14%). In univariate analysis, the patients receiving inadequate or no treatment were older, tended to be non-Caucasian, had a lower income, and had a higher comorbidity score. Patients undergoing adequate treatment had improved overall survival (OS) compared with those receiving inadequate or no treatment (median OS, 34.0 months vs 11.7 months; P < .001). Of those receiving adequate treatment, logistic regression identified several variables associated with surgical resection, including treatment at an academic facility, Caucasian race, and annual income >$35,000. Increasing age and T2 stage were associated with nonoperative management. Following propensity score matching of 2308 patient pairs undergoing surgery or CRT, resection was associated with longer median OS (34.1 months vs 22.0 months; P < .001).
  
  
  CONCLUSIONS
  Despite the established guidelines, many patients with T1-2N1 NSCLC do not receive adequate treatment. Surgery is associated with prolonged survival in selected patients. Surgical input in the multidisciplinary evaluation of these patients should be mandatory.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bott
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Aalok P
authors.initials: AP
authors.lastname: Patel
authors.affiliation: Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Neb.
authors.forename: Vivek
authors.initials: V
authors.lastname: Verma
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Traves D
authors.initials: TD
authors.lastname: Crabtree
authors.affiliation: Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Mo.
authors.forename: Daniel
authors.initials: D
authors.lastname: Morgensztern
authors.affiliation: Department of Radiation Oncology, Washington University School of Medicine, St Louis, Mo.
authors.forename: Clifford G
authors.initials: CG
authors.lastname: Robinson
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Graham A
authors.initials: GA
authors.lastname: Colditz
authors.affiliation: Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Mo.
authors.forename: Saiama
authors.initials: S
authors.lastname: Waqar
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: A Sasha
authors.initials: AS
authors.lastname: Krupnick
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Stephen
authors.initials: S
authors.lastname: Broderick
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Bryan F
authors.initials: BF
authors.lastname: Meyers
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo. Electronic address: puriv@wudosis.wustl.edu.
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D059248:Chemoradiotherapy; D017024:Chemotherapy, Adjuvant; D016208:Databases, Factual; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011013:Pneumonectomy; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D057216:Propensity Score; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States
keywords: locally advanced; lymph nodes; multi-modality therapy; non–small cell lung cancer; practice patterns; surgical resection