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Ann Thorac Surg 2008;85:1850-1856. doi:10.1016/j.athoracsur.2007.12.081
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Temporal Trends in the Management of Potentially Resectable Lung Cancer

Farhood Farjah, MD, MPHa, Douglas E. Wood, MDb, David Yanez, III, PhDc, Rebecca G. Symons, MPHa, Bahirathan Krishnadasan, MDb, David R. Flum, MD, MPHa,d,*

a Surgical Outcomes Research Center, University of Washington, Seattle, Washington
b Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washington
c Department of Biostatistics, University of Washington, Seattle, Washington
d Division of General Surgery, Department of Surgery, University of Washington, Seattle, Washington

Accepted for publication December 18, 2007.

* Address correspondence to Dr Flum, Department of Surgery, University of Washington, 1959 NE Pacific, Box 356410, Seattle, WA 98195-6310; (Email: daveflum{at}u.washington.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

Background: Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time.

Methods: This investigation was a cohort study of tumor-registry data linked to Medicare claims.

Results: Between 1992 and 2002, 24,030 patients—mean age 75 ± 6 years, 55% men—were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97).

Conclusions: Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.






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