Lung cancer is the leading cause of cancer death in the United States. Although optimal treatment for non-small cell lung cancer (NSCLC) is surgical resection, most patients are ineligible as they present with advanced disease. A resection rate of 25% has been reported in the US while in the United Kingdom rates may be as low as 5%. Pre-operative delays may contribute to this discrepancy and in 1999 the Birmingham VA established a specialized Lung Mass Clinic (LMC) to streamline care. We hypothesized that since then, the resection rate would be comparable to US standards.
We examined the medical records of all veterans seen in the LMC between October 1999 and October 2003 and identified those subsequently diagnosed with NSCLC. Baseline demographics and pulmonary function were recorded as were diagnostic methods, times to diagnosis and resection, and post-operative survival. Reasons for non-resection were tabulated. Differences between those resected and non-resected were examined using Chi Square or t-tests as appropriate.
157 patients were diagnosed with NSCLC and 31 (19.7%) underwent resection. There were no differences in age, race, or sex between the two groups although resected patients had better pulmonary function (Table 1). Patients diagnosed by bronchoscopy were less likely to undergo resection. The median time to diagnosis was 70 days in those resected and 8 days in the non-resected group (P<0.001). The median time to resection was 104 days. To date, time to resection does not correlate with post-operative survival. 106 (84%) of those not resected had evidence of advanced disease, poor pulmonary function, or refused therapy (Table 2).
TABLE 1Resected (N=31)Not Resected (N=126)p ValueAge (years)64.866.80.28Race (% Caucasian)84740.35Sex (% Male)9799NSFEV1 (mean % predicted)67550.002FVC (mean % predicted)71620.02Method of diagnosisBronchoscopy (% total)10/31 (32)97/126 (77)<0.001Surgery (% total)19/31 (61)9/126 (7)<0.001TTNA (% total)2/31 (6)19/126 (15)NSMedian time to diagnosis (days)708<0.001TABLE 2Primary Reason for Non-Resection (N=126)# (%Total)Advanced disease by imaging53 (42)IIIA/IIIB disease- transbronchial needle aspiration29 (23)Biopsy proven distant metastases7 (6)IIIA/IIIB disease –mediastinoscopy6 (5)Pulmonary function6 (5)Refused treatment5 (4)Comorbidities/poor functional status5 (4)Died during evaluation4 (3)Lost to follow-up/unknown11 (9)
Since the inception of the LMC, the resection rate appears comparable to that observed nationally. Those whose disease was amenable to bronchoscopic diagnosis had faster tissue confirmation but were unlikely to undergo resection. The primary determinant of the resection rate was advanced stage at presentation and not pre-operative delays.
The VA performs as well as other health systems in the surgical treatment of lung cancer.
B.J. Lock, None.