title: National Cancer Database Analysis of Proton Versus Photon Radiation Therapy in Non-Small Cell Lung Cancer.
abstract: To analyze outcomes and predictors associated with proton radiation therapy for non-small cell lung cancer (NSCLC) in the National Cancer Database.
  
  
  
  The National Cancer Database was queried to capture patients with stage I-IV NSCLC treated with thoracic radiation from 2004 to 2012. A logistic regression model was used to determine the predictors for utilization of proton radiation therapy. The univariate and multivariable association with overall survival were assessed by Cox proportional hazards models along with log-rank tests. A propensity score matching method was implemented to balance baseline covariates and eliminate selection bias.
  
  
  
  A total of 243,822 patients (photon radiation therapy: 243,474; proton radiation therapy: 348) were included in the analysis. Patients in a ZIP code with a median income of <$46,000 per year were less likely to receive proton treatment, with the income cohort of $30,000 to $35,999 least likely to receive proton therapy (odds ratio 0.63 [95% confidence interval (CI) 0.44-0.90]; P=.011). On multivariate analysis of all patients, non-proton therapy was associated with significantly worse survival compared with proton therapy (hazard ratio 1.21 [95% CI 1.06-1.39]; P<.01). On propensity matched analysis, proton radiation therapy (n=309) was associated with better 5-year overall survival compared with non-proton radiation therapy (n=1549), 22% versus 16% (P=.025). For stage II and III patients, non-proton radiation therapy was associated with worse survival compared with proton radiation therapy (hazard ratio 1.35 [95% CI 1.10-1.64], P<.01).
  
  
  
  Thoracic radiation with protons is associated with better survival in this retrospective analysis; further validation in the randomized setting is needed to account for any imbalances in patient characteristics, including positron emission tomography-computed tomography staging.
authors.affiliation: Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia. Electronic address: kristin.higgins@emory.edu.
authors.forename: Kristin A
authors.initials: KA
authors.lastname: Higgins
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Kelli
authors.initials: K
authors.lastname: O'Connell
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Liu
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Surgery, Emory University, Atlanta, Georgia.
authors.forename: Theresa W
authors.initials: TW
authors.lastname: Gillespie
authors.affiliation: Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Mark W
authors.initials: MW
authors.lastname: McDonald
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia.
authors.forename: Rathi N
authors.initials: RN
authors.lastname: Pillai
authors.affiliation: Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Kirtesh R
authors.initials: KR
authors.lastname: Patel
authors.affiliation: Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Pretesh R
authors.initials: PR
authors.lastname: Patel
authors.affiliation: Department of Radiation Oncology, Washington University, St. Louis, Missouri.
authors.forename: Clifford G
authors.initials: CG
authors.lastname: Robinson
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Charles B
authors.initials: CB
authors.lastname: Simone
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia.
authors.forename: Taofeek K
authors.initials: TK
authors.lastname: Owonikoko
authors.affiliation: Penn State Hershey Cancer Institute, Pennsylvania University, Hershey, Pennsylvania.
authors.forename: Chandra P
authors.initials: CP
authors.lastname: Belani
authors.affiliation: Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia; American University of Beirut, Beirut, Lebanon.
authors.forename: Fadlo R
authors.initials: FR
authors.lastname: Khuri
authors.affiliation: Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
authors.forename: Walter J
authors.initials: WJ
authors.lastname: Curran
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia.
authors.forename: Suresh S
authors.initials: SS
authors.lastname: Ramalingam
authors.affiliation: Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia.
authors.forename: Madhusmita
authors.initials: M
authors.lastname: Behera
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D016001:Confidence Intervals; D016208:Databases, Factual / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007182:Income; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009367:Neoplasm Staging / Q000706:statistics & numerical data; D016017:Odds Ratio; D017785:Photons / Q000627:therapeutic use*; D057216:Propensity Score; D061766:Proton Therapy / Q000191:economics / Q000401:mortality / Q000706:statistics & numerical data; D012189:Retrospective Studies; D015983:Selection Bias; D016896:Treatment Outcome; D014481:United States