Health Services Research & Development

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Stokes SM, Massarweh NN, Stringham JR, Varghese TK. Clinical-Pathologic Correlation and Guideline Concordance in Resectable Non-Small Cell Lung Cancer. The Annals of thoracic surgery. 2019 Sep 1; 108(3):837-844.
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Abstract: BACKGROUND: Accurate staging of non-small cell lung cancer (NSCLC) is critical for identifying patients who will benefit from multimodality therapy. This study evaluated clinical-pathologic correlation and its effects on receipt of guideline-concordant therapy in a national cohort. METHODS: A retrospective cohort study of patients with surgically resected NSCLC in the National Cancer Database (NCDB) between 2004 and 2014 was conducted. Primary tumor and nodal staging information was analyzed in patients who underwent upfront surgery and neoadjuvant therapy to calculate correlation between clinical and pathologic stages and estimate downstaging rate. Staging accuracy and Spearman''s rank correlation coefficients were calculated. Multivariable Cox regression was used to evaluate the association between receipt of guideline-concordant therapy and overall risk of death. RESULTS: Among 82,999 patients, correlation between clinical and pathologic stages was strong (r = 0.69). Correlation of primary tumor staging was high (71.2%-84.5%). The positive predictive value of nodal staging was 78.2%. Neoadjuvant therapy was associated with downstaging in tumor stage (T1, 1.5%; T2, 22.6%; T3, 28%; T4, 42%) and 17.3% of positive nodes. Patients with stage I disease had high rates of guideline-concordant treatment (IA, 97.4%; and IB, 97.9%). Patients with stage IIA to IIIA disease had lower rates of guideline concordance. Receipt of guideline-concordant care was associated with a significantly lower risk of death (hazard ratio, 0.84; 95% confidence interval, 0.80-0.87). CONCLUSIONS: Clinical staging modalities are reasonably accurate. However, less than one half of patients with stage IIA to IIIA NSCLC receive guideline-concordant therapy, and this deficiency is associated with inferior survival. Identifying factors contributing to these differences is crucial to improve outcomes.