Association of socioeconomic factors with the receipt of neoadjuvant therapy for patients with non-small cell lung cancer

BACKGROUND

Neoadjuvant therapy (NT) will be increasingly used for patients with non-small cell lung cancer (NSCLC), particularly given the recent approval of neoadjuvant chemoimmunotherapy. Several barriers may prevent the uptake of NT and should be identified and addressed. We queried the National Cancer Database (NCDB) to determine predictors of the use of NT.

METHODS

Using the NCDB (2006-2019), we identified 80,707 patients who underwent surgery for clinical stage II and III NSCLC. Sociodemographic and clinical factors were reviewed, and univariable and multivariable analyses were performed to identify associations with the uptake of NT. In propensity score-matched groups, survival was determined using the Kaplan-Meier method.

RESULTS

Among 80,707 eligible patients, 17,262 (21.4%) received NT. Clinical stage and node positivity were associated with receipt of NT. On multivariable analysis, factors associated with lower rates of NT included black race (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.67-0.90), Charlson Comorbidity Index ≥2 (OR, 0.75; 95% CI, 0.67-0.85), Medicaid/Medicare insurance (OR, 0.82; 95% CI, 0.75-0.90), lower income level (OR, 0.79; 95% CI, 0.71-0.87), and treatment at a community center (OR, 0.81; 95% CI, 0.67-0.96). In an exploratory analysis, those patients who received NT had longer 5-year overall survival compared with those who did not (48.3% vs 46.0%; P < .001).

CONCLUSIONS

Rates of NT are relatively low for patients with clinical stage II/III NSCLC treated prior to recent chemoimmunotherapy trials. Socioeconomic barriers to the uptake of NT include race, insurance status, income, and area of residence. As NT becomes more widely offered, accessibility for vulnerable populations must be assured.

Minimally invasive surgery for clinical T4 non-small-cell lung cancer: national trends and outcomes

OBJECTIVES

Recent randomized data support the perioperative benefits of minimally invasive surgery (MIS) for non-small-cell lung cancer (NSCLC). Its utility for cT4 tumours remains understudied. We, therefore, sought to analyse national trends and outcomes of minimally invasive resections for cT4 cancers.

METHODS

Using the 2010-2019 National Cancer Database, we identified patients with cT4N0-1 NSCLC. Patients were stratified by surgical approach. Multivariable logistic analysis was used to identify factors associated with use of a minimally invasive approach. Groups were matched using propensity score analysis to evaluate perioperative and survival end points.

RESULTS

The study identified 3715 patients, among whom 64.1% (n = 2381) underwent open resection and 35.9% (n = 1334) minimally invasive resection [robotic-assisted in 31.5% (n = 420); and video-assisted in 68.5% (n = 914)]. Increased MIS use was noted among patients with higher income [≥$40 227, odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.51] and those treated at academic hospitals (OR 1.25; 95% CI 1.07-1.45). Clinically node-positive patients (OR 0.68; 95% CI 0.55-0.83) and those who underwent neoadjuvant therapy (OR 0.78; 95% CI 0.65-0.93) were less likely to have minimally invasive resection. In matched groups, patients undergoing MIS had a shorter median length of stay (5 vs 6 days, P < 0.001) and no significant differences between 30-day readmissions or 30/90-day mortality. MIS did not compromise overall survival (log-rank P = 0.487).

CONCLUSIONS

Nationally, the use of minimally invasive approaches for patients with cT4N0-1M0 NSCLC has increased substantially. In these patients, MIS is safe and does not compromise perioperative outcomes or survival.