Invasive nodal evaluation prior to stereotactic ablative radiation for non-small cell lung cancer

Jeremy P. Harris, Chika Nwachukwu, Yushen Qian, Erqi Pollom, Billy W. Loo, Millie Das, Maximilian Diehn

Research output: Contribution to journalArticle

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Abstract

Introduction: Invasive nodal evaluation (INE) is used to improve staging for early stage non-small cell lung cancer (NSCLC), including when stereotactic ablative radiation (SABR) is used. Consensus guidelines from the NCCN recommend performing INE for patients with T2N0 tumors and considering INE for those with T1N0 tumors. We reasoned that if INE results in significant stage migration in the form of substantially fewer patients with occult nodal involvement, then patients treated with SABR who do not undergo INE should have worse overall survival (OS). Methods: Patients diagnosed 2004–2014 with stage T1–2N0M0 NSCLC and treated with SABR were identified from the National Cancer Database. Factors associated with INE were determined using mixed effects logistic regression. We tested for an association between INE and OS for patients diagnosed 2004–2013 using mixed effects proportional hazards regression methods. Results: 24,603 SABR patients were identified. 6% of the 19,322 patients with T1 tumors and 9% of the 5281 patients with T2 tumors had INE. Median OS was 2.8 years for the no-INE group and 2.7 years for the INE group (log-rank P = 0.69). No significant association was observed between the use of INE and OS in the univariate analysis (HR 1.02, 95% CI 0.94–1.11) or the multivariate analysis (HR 0.94, 95% CI 0.86–1.02). These findings were confirmed using propensity score matched and instrumental variable analysis. On subgroup analysis, INE was associated with a non-significant trend for improved OS in patients with T2 tumors (HR 0.87, 95% CI 0.76–1.00) but not T1 tumors (HR 0.98, 95% CI 0.88–1.09). Conclusions: Despite current NCCN recommendations, the rate of INE was low for patients with stage T1 or T2 tumors. While omitting INE represents a compromise in the completeness of nodal evaluation, we found that it was not associated with a detriment in overall survival.

Original languageEnglish (US)
Pages (from-to)76-85
Number of pages10
JournalLung Cancer
Volume124
DOIs
StatePublished - Oct 2018
Externally publishedYes

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Non-Small Cell Lung Carcinoma
Radiation
Survival
Neoplasms
Propensity Score
Multivariate Analysis
Logistic Models

Keywords

  • Lymph nodes
  • Non-small cell lung cancer
  • Staging
  • Stereotactic body radiation

ASJC Scopus subject areas

  • Oncology
  • Pulmonary and Respiratory Medicine
  • Cancer Research

Cite this

Invasive nodal evaluation prior to stereotactic ablative radiation for non-small cell lung cancer. / Harris, Jeremy P.; Nwachukwu, Chika; Qian, Yushen; Pollom, Erqi; Loo, Billy W.; Das, Millie; Diehn, Maximilian.

In: Lung Cancer, Vol. 124, 10.2018, p. 76-85.

Research output: Contribution to journalArticle

Harris, Jeremy P. ; Nwachukwu, Chika ; Qian, Yushen ; Pollom, Erqi ; Loo, Billy W. ; Das, Millie ; Diehn, Maximilian. / Invasive nodal evaluation prior to stereotactic ablative radiation for non-small cell lung cancer. In: Lung Cancer. 2018 ; Vol. 124. pp. 76-85.
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abstract = "Introduction: Invasive nodal evaluation (INE) is used to improve staging for early stage non-small cell lung cancer (NSCLC), including when stereotactic ablative radiation (SABR) is used. Consensus guidelines from the NCCN recommend performing INE for patients with T2N0 tumors and considering INE for those with T1N0 tumors. We reasoned that if INE results in significant stage migration in the form of substantially fewer patients with occult nodal involvement, then patients treated with SABR who do not undergo INE should have worse overall survival (OS). Methods: Patients diagnosed 2004–2014 with stage T1–2N0M0 NSCLC and treated with SABR were identified from the National Cancer Database. Factors associated with INE were determined using mixed effects logistic regression. We tested for an association between INE and OS for patients diagnosed 2004–2013 using mixed effects proportional hazards regression methods. Results: 24,603 SABR patients were identified. 6{\%} of the 19,322 patients with T1 tumors and 9{\%} of the 5281 patients with T2 tumors had INE. Median OS was 2.8 years for the no-INE group and 2.7 years for the INE group (log-rank P = 0.69). No significant association was observed between the use of INE and OS in the univariate analysis (HR 1.02, 95{\%} CI 0.94–1.11) or the multivariate analysis (HR 0.94, 95{\%} CI 0.86–1.02). These findings were confirmed using propensity score matched and instrumental variable analysis. On subgroup analysis, INE was associated with a non-significant trend for improved OS in patients with T2 tumors (HR 0.87, 95{\%} CI 0.76–1.00) but not T1 tumors (HR 0.98, 95{\%} CI 0.88–1.09). Conclusions: Despite current NCCN recommendations, the rate of INE was low for patients with stage T1 or T2 tumors. While omitting INE represents a compromise in the completeness of nodal evaluation, we found that it was not associated with a detriment in overall survival.",
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T1 - Invasive nodal evaluation prior to stereotactic ablative radiation for non-small cell lung cancer

AU - Harris, Jeremy P.

AU - Nwachukwu, Chika

AU - Qian, Yushen

AU - Pollom, Erqi

AU - Loo, Billy W.

AU - Das, Millie

AU - Diehn, Maximilian

PY - 2018/10

Y1 - 2018/10

N2 - Introduction: Invasive nodal evaluation (INE) is used to improve staging for early stage non-small cell lung cancer (NSCLC), including when stereotactic ablative radiation (SABR) is used. Consensus guidelines from the NCCN recommend performing INE for patients with T2N0 tumors and considering INE for those with T1N0 tumors. We reasoned that if INE results in significant stage migration in the form of substantially fewer patients with occult nodal involvement, then patients treated with SABR who do not undergo INE should have worse overall survival (OS). Methods: Patients diagnosed 2004–2014 with stage T1–2N0M0 NSCLC and treated with SABR were identified from the National Cancer Database. Factors associated with INE were determined using mixed effects logistic regression. We tested for an association between INE and OS for patients diagnosed 2004–2013 using mixed effects proportional hazards regression methods. Results: 24,603 SABR patients were identified. 6% of the 19,322 patients with T1 tumors and 9% of the 5281 patients with T2 tumors had INE. Median OS was 2.8 years for the no-INE group and 2.7 years for the INE group (log-rank P = 0.69). No significant association was observed between the use of INE and OS in the univariate analysis (HR 1.02, 95% CI 0.94–1.11) or the multivariate analysis (HR 0.94, 95% CI 0.86–1.02). These findings were confirmed using propensity score matched and instrumental variable analysis. On subgroup analysis, INE was associated with a non-significant trend for improved OS in patients with T2 tumors (HR 0.87, 95% CI 0.76–1.00) but not T1 tumors (HR 0.98, 95% CI 0.88–1.09). Conclusions: Despite current NCCN recommendations, the rate of INE was low for patients with stage T1 or T2 tumors. While omitting INE represents a compromise in the completeness of nodal evaluation, we found that it was not associated with a detriment in overall survival.

AB - Introduction: Invasive nodal evaluation (INE) is used to improve staging for early stage non-small cell lung cancer (NSCLC), including when stereotactic ablative radiation (SABR) is used. Consensus guidelines from the NCCN recommend performing INE for patients with T2N0 tumors and considering INE for those with T1N0 tumors. We reasoned that if INE results in significant stage migration in the form of substantially fewer patients with occult nodal involvement, then patients treated with SABR who do not undergo INE should have worse overall survival (OS). Methods: Patients diagnosed 2004–2014 with stage T1–2N0M0 NSCLC and treated with SABR were identified from the National Cancer Database. Factors associated with INE were determined using mixed effects logistic regression. We tested for an association between INE and OS for patients diagnosed 2004–2013 using mixed effects proportional hazards regression methods. Results: 24,603 SABR patients were identified. 6% of the 19,322 patients with T1 tumors and 9% of the 5281 patients with T2 tumors had INE. Median OS was 2.8 years for the no-INE group and 2.7 years for the INE group (log-rank P = 0.69). No significant association was observed between the use of INE and OS in the univariate analysis (HR 1.02, 95% CI 0.94–1.11) or the multivariate analysis (HR 0.94, 95% CI 0.86–1.02). These findings were confirmed using propensity score matched and instrumental variable analysis. On subgroup analysis, INE was associated with a non-significant trend for improved OS in patients with T2 tumors (HR 0.87, 95% CI 0.76–1.00) but not T1 tumors (HR 0.98, 95% CI 0.88–1.09). Conclusions: Despite current NCCN recommendations, the rate of INE was low for patients with stage T1 or T2 tumors. While omitting INE represents a compromise in the completeness of nodal evaluation, we found that it was not associated with a detriment in overall survival.

KW - Lymph nodes

KW - Non-small cell lung cancer

KW - Staging

KW - Stereotactic body radiation

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