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Neoadjuvant Chemotherapy vs Neoadjuvant Chemo-radiation Preceding Surgical Resection for Clinical N2/Stage IIIA Non-Small Cell Lung Cancer: A Review of the National Cancer Database (NCDB)
Megan Cibulas, MD1, Nikhil Sikha, MPH2, Francisco Tarrazzi, MD1, Mark Block, MD1, Syed Razi, MD1.
1Memorial Healthcare System, Pembroke Pines, FL, USA, 2Florida State University, Tallahassee, FL, USA.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) recommends stage IIIA non-small cell lung cancer (NSCLC) management with induction chemotherapy (i-CT) +/- radiation (i-CRT) followed by resection. Literature strongly supports the safety and survival benefit of preoperative chemotherapy in potentially resectable NSCLC; however, the utility and timing of radiation therapy remains controversial. This study compares survival and postoperative outcomes associated with i-CT and i-CRT. METHODS: The National Cancer Database (NCDB) was queried between 2004-2014 for patients with clinical stage IIIA NSCLC. Inclusion criteria were squamous cell or adenocarcinoma, tumor size up to 5 cm, N2, M0, and i-CT or i-CRT prior to lobectomy. Kaplan-Meier and Cox regression models were utilized to evaluate long term survival, and chi-squared analyses were used to compare surgical margins, nodal downstaging, hospital length of stay (LOS), 30-day unplanned readmissions, and 30-day mortality. RESULTS: 2,009 patients met our inclusion criteria with 792 patients receiving i-CT and 1,217 receiving i-CRT. Patients who received i-CRT had significantly more nodal downstaging with no difference in surgical margins or 30-day mortality (Table 1). The i-CRT group was associated with both increased LOS and 30-day unplanned readmissions. No survival difference was observed between i-CRT and i-CT (HR 1.052, 95% CI, 0.91-1.21; p = 0.49) (Figure 1). CONCLUSIONS: Routine use of neoadjuvant radiation for stage IIIA NSCLC does not offer long-term survival benefit and is likely associated with increased postoperative morbidity. Further studies are needed to elucidate the potential benefit of nodal downstaging with preoperative radiation treatment.

Table 1
i-CT [n = 792]i-CRT [n = 1,217]p-value
Surgical Margins29 (3.7%)47 (3.9%)0.45
Nodal Downstaging338 (42.7%)579 (47.6%)0.017
Hospital LOS [Median/Interquartile Range]5 [3-7]5 [4-8]<0.001
30-day Unplanned Readmissions18 (2.3%)50 (4.1%)0.031
30-day Mortality7 (1%)6 (0.6%)0.44
Key: induction chemotherapy (i-CT), induction chemoradiation (i-CRT), length of stay (LOS)


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