Erastin br In patients who received
In patients who received neoadjuvant therapy, any pathologic response was predictive of a significantly decreased risk of death (0.82, 95%CI 0.75-0.92). This held true across all stages (Supplementary Table 1). Compared to accurately staged patients, patients who were understaged had increased risk of death (1.63, 95%CI 1.58-1.69), while those who were overstaged had lower risk of death (0.72, 95%CI 0.68-0.76). (Supplementary Table 1)
Medicaid/uninsured insurance, rurality, longer travel distance, Charlson-Deyo>1, high grade, positive margins, and positive Erastin nodes. (Supplementary Table 2) Guideline concordance for Stage IA and IB patients was high (97.4% and 97.9% respectively). Stage IIA (49.2%), IIB (47.5%), and IIIA patients (32.2%) had lower rates. Using more stringent criteria for neoadjuvant therapy, guideline concordance was much lower for Stage IIIA due to inadequate radiotherapy doses (Stage IA 97.7%, Stage IB 99.1%, Stage IIA 50.5%, Stage IIB 49.6%, Stage IIIA 18.7%). The sensitivity analysis using more stringent guideline criteria did not change the survival analyses, thus the more broad definition of neoadjuvant therapy was used. Patients who received guideline-concordant care were more likely to have negative margins (87.5% vs.
In patients with Stage IIIA disease, patients who responded to neoadjuvant therapy had higher unadjusted five-year OS (54.7% vs 45.5% no disease response vs 49.6% guideline discordant, Figure 2). After adjustment, patients who received neoadjuvant therapy without response had a significantly higher risk of death than those who did not receive neoadjuvant therapy (HR 1.22, 95%CI 1.11-1.34). However, there was no difference in risk of death between those who received neoadjuvant therapy with a disease response and those who did not receive neoadjuvant therapy. (HR 0.94, 95%CI 0.85-1.04). Directly comparing patients who responded and who did not respond to neoadjuvant therapy, lack of response was associated with increased risk of death (HR 1.29, 95%CI 1.15-1.45).
Accurate clinical staging of patients with NSCLC is essential.3 Historically, clinical staging modalities for NSCLC have poor correlation with pathologic findings. Despite established national guidelines for the management of NSCLC, the extent to which patients in the US receive guideline-concordant care remains unclear. In that light, our data support several important conclusions. First, the correlation between clinical and pathologic staging is better than in previous reports supporting the use of clinical staging for decision-making on multi-modal treatment. However, improvement of nodal staging accuracy is still needed given only moderate correlation. Second, while adherence to guidelines is good for those with early stage disease, only 42.6% of those with stage IIA-IIIA disease receive guideline-concordant care. Finally, receipt of guideline-concordant care is generally associated with a survival benefit.
Historically, studies examining clinical-pathologic correlation have been single-center,
retrospective studies.5-7 These studies consistently demonstrate staging modalities for NSCLC tend to be poor indicators of final pathologic staging except in early stage disease. A more recent prospective study from the Dutch Lung Surgery Audit of 1,555 patients found overall
stage concordance of 59.9%.8 Accuracy of T staging within triplet study ranged from 45.2% to 68.9%. Importantly, 22.6% of patients were found to be upstaged after presenting with Stage I disease leading these patients to receive adjuvant therapy. Our data, derived from a variety of different practice settings, demonstrate acceptable tumor and nodal staging correlation. However, nodal evaluation still has room for improvement. The decrease in correlation with nodal staging is partially due to the failure of imaging to identify clinically positive nodes contributing to lower staging accuracy in higher stage disease. Perhaps more salient is the difficulty of invasive mediastinal staging. Adequacy of invasive staging has been found to be