Hospital Utilization of Stereotactic Body Radiation Therapy and Rates of Surgical Refusal in the Setting of Early Stage Non-Small Cell Lung Cancer (NSCLC)


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Presentation: 12:04

Mentor: Olugbenga Okusanya, MD, Thoracic Surgery, Thomas Jefferson University Hospital

Awards: 2021 Faculty Seed Grant; 2021 IASLC Staging Project 9th edition; 2022 Saligman Grant


Background: Increasingly, stereotactic body ratio therapy (SBRT) is utilized for patients unfit or unwilling to undergo surgery for early stage non-small cell lung cancer (NSCLC). There is limited data to support SBRT as equivalent to surgical resection, but utilization as a primary treatment modality has grown substantially over the last ten years. It remains unclear how SBRT utilization has influenced patient refusal of surgical resection.

Methods: A retrospective cohort analysis was completed using the National Cancer Database (NCDB) for patients with T1/T2NOMO lesions, 2008-2017. Propensity-score matching was used to compare rates of surgical refusal and rates of post-refusal receipt of radiation. Facilities were categorized by SBRT/Surgery ratio for each year of analysis; facilities performing higher than the median ratio were designated as high ratio facilities. Multivariable regression analysis was performed to evaluate effect size.

Results: In total, 129,901 patients were included in the analysis, 84,320 treated at Low SBRT/Surgeryutilization facilities and 45,581 at High SBRT/Surgery facilities. The SBRT/Surgery utilization cutoff (median) in 2008 was 18.5% and in 2017 it was 33.3%. Surgical refusal rate differed between cohorts (Low SBRT/Surg: 2.5% vs. High SBRT/Surg: 6.1%, p<0.001). Patients refusing surgery at High SBRT/Surg facilities were younger (76 years vs. 75 years, p=0.003), had fewer comorbid conditions (CCI ≥1, 41.0% vs. 37.9%, P=0.03), and had smaller tumors (2.4cm vs. 2.2cm, P<0.01). Rates of SBRT following surgical refusal differed (Low SBRT/Surg: 21.9% vs. High SBRT/Surg: 50.6%, p<0.001). In a matched cohort of 76,636, surgical refusal differed (Low SBRT/Surg: 4.2% vs. High SBRT/Surg: 6.0%, p<0.001). The rates of receiving SBRT after declining surgery were higher at High SBRT/Surg ratio facilities (0.5% vs 3.0%, p<0.001. On multivariable regression, the treatment at top quartile SBRT/Surg-utilizing facility was the largest risk factor for surgical refusal, OR: 5.01 (4.57-5.49, p<0.001) and was most strongly associated with post-refusal SBRT, OR: 8.29 (3.57-5.54, p<0.001).

Conclusions: Patients treated at high SBRT-utilizing facilities are more likely to refuse surgical resection for early stage lung cancers, and are more likely to receive radiation therapy following surgical refusal. Further analysis is needed to better understand factors influencing patient refusal of surgery in the setting of early NSCLC, and how facility-level practice patterns may impact these decisions.



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