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Nasser Altorki



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    OA06 - Early Stage Lung Cancer: Outcomes and Interventions (ID 902)

    • Event: WCLC 2018
    • Type: Oral Abstract Session
    • Track: Treatment of Early Stage/Localized Disease
    • Presentations: 2
    • Now Available
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      OA06.03 - Sublobar Resection is Equivalent to Lobectomy for Screen Detected Lung Cancer (Now Available) (ID 13968)

      13:50 - 14:00  |  Author(s): Nasser Altorki

      • Abstract
      • Presentation

      Background

      Despite the lack of survival data from modern, ongoing randomized clinical trials (CALGB 140503, JCOG 0802), sublobar resection (SLR) is increasingly offered to patients with small, peripheral lung cancers. In particular, SLR may be an attractive surgical strategy for screen detected lung cancers, some of which may be less biologically aggressive than cancers detected by other means. Utilizing prospective data collected from patients undergoing surgery in the National Lung Screening Trial (NLST), we sought to determine whether the extent of resection affected survival for patients with screen detected lung cancer.

      Method

      The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer. Numerical variables were compared using Mann-Whitney U test. Categorical variables were compared using Chi-squared test. Propensity score matching analysis (lobectomy versus sublobar resection) controlling for age, gender, race, tumor size, and stage was performed (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Overall survival (OS) and cancer specific survival (CSS) were compared using log rank test in Kaplan Meier curves.

      Result

      Among 1,029 patients who underwent resection for lung cancer, we identified 821 patients (80%) who had lobectomy and 166 patients (16%) who had SLR, among whom the majority (n=114, 69%) had wedge resection. Patients who underwent SLR were older (64 vs. 61, p=0.66), more likely to be female (53% vs. 41%, p=0.004), had smaller tumors (2 cm vs. 4.5 cm, p<0.001), and were more likely to be stage I (80% vs. 75%, p=0.001). At five years, for stage I patients undergoing SLR (n=129) there was no difference in OS (77% vs. 77%, p=0.889) or CSS (83% vs. 83%, p=0.959) compared to patients undergoing lobectomy (n=613). In order to more accurately compare surgical outcomes, we propensity matched 134 patients from each group undergoing SLR and lobectomy. Among these matched groups, there were no differences in age, gender, histology, or stage. Postoperatively, patients undergoing SLR had less total complications (22% vs. 32%, p=0.05) than those undergoing lobectomy (HR 0.59, CI 0.38-0.94). In matched patients at five years, there was no difference in OS (67% vs. 70%, p=0.629) or CSS (74% vs. 74%, p=0.980) for patients undergoing SLR compared to those undergoing lobectomy.

      Conclusion

      For patients with screen detected lung cancer, SLR confers equivalent survival to lobectomy. By decreasing perioperative complications and potentially preserving lung function, SLR may provide distinct advantages in a screen detected lung cancer patient cohort.

      Information from this presentation has been removed upon request of the author.

      Information from this presentation has been removed upon request of the author.

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      OA06.07 - Predictors and Consequences of Refusing Surgery for Clinical Stage I NSCLC: A National Cancer Database Analysis (Now Available) (ID 13865)

      14:35 - 14:45  |  Author(s): Nasser Altorki

      • Abstract
      • Presentation

      Background

      Given perceived morbidity of lung cancer surgery, patients may instead pursue other treatment options, particularly in the current era of shared decision-making. We sought to determine predictors of refusal of surgery for clinical stage I non-small cell lung cancer (NSCLC) patients and to determine associated outcomes.

      Method

      The NCDB (2004-2014) was queried for clinical stage I NSCLC patients who underwent or were recommended to undergo surgery. A unique field in the NCDB allows identification of those patients who were recommended to have surgery, but refused. We only included cases in which surgery was refused “by the patient, patient’s family member or guardian”. We excluded patients with multiple primary tumors, unknown treatment modality/sequence, those who did not undergo recommended surgery for unknown reasons, and those initially not recommended to have surgery. Survival was compared using log rank test in Kaplan Meier curves. Logistic regression was performed to identify predictors of refusing surgery.

      Result

      We identified 118,0217 patients undergoing surgery and 3,210 (2.6%) who were recommended, but refused surgery. By multivariate analysis older age (HR=1.09, CI=1.08-1.09), non-white race (HR=2.18, CI=1.97-2.42), low income (HR=1.28,CI=1.16-1.41), lack of insurance (HR=2.62,CI=1.89-3.62), squamous histology (HR=1.40,CI=1.29-1.53), and larger tumor size (HR=1.57,CI=1.42-1.73) predicted refusal of surgery.Patients refusing surgery were treated with chemoradiation (n=249, 7.8%), radiation or chemotherapy alone (n=1,568, 48.8%), or no treatment (n=1393, 43.4%). Median survival was worse for patients who refused any treatment versus those who received other treatment modalities (19.8 vs 42.2 months, P<0.001). Among those patients refusing surgery who were treated with radiation, we identified 758 patients (23.6%) who received stereotactic body radiation therapy (SBRT). The proportion of patients who refused surgery and received SBRT increased over time, from 3.8% in 2004-2006, to 17% in 2007-2009, to 31.1% in 2010-2012, and to 37.9% in 2013-2014. Patients receiving SBRT had improved survival compared to other patients refusing surgery (47.9 vs. 25.2 months, p<0.001), although survival in the SBRT group was inferior to patients undergoing surgery as recommended (47.9 vs. 82.8 months, p<0.001).

      Conclusion

      Although patients may be reluctant to undergo surgery for early stage NSCLC, refusal of surgery when recommended comes at the expense of decreased survival. Socioeconomic factors may be associated with refusal of surgery. The use of SBRT is an effective and increasingly used alternative in these patients, which improves survival compared to no treatment but which is still not equivalent to surgery in this unmatched, retrospective cohort.

      Information from this presentation has been removed upon request of the author.

      Information from this presentation has been removed upon request of the author.

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    P1.16 - Treatment of Early Stage/Localized Disease (Not CME Accredited Session) (ID 948)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
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      P1.16-49 - Treatment of NSCLC Patients with Clinical N1 Disease: Is There an Advantage to Neoadjuvant Therapy? (Now Available) (ID 14106)

      16:45 - 18:00  |  Author(s): Nasser Altorki

      • Abstract
      • Slides

      Background

      Treatment options for clinical N1 patients with non-small cell lung cancer (NSCLC) include neoadjuvant therapy and surgery, surgery with adjuvant therapy, or definitive chemoradiation (dCRT). We sought to evaluate the rates of use of each strategy and associated outcomes in patients in the National Cancer Database (NCDB).

      Method

      The NCDB (2004-2014) was reviewed for patients with clinical N1 NSCLC, excluding those with multiple primary tumors, unknown treatment modality/sequence, and clinical M1 disease. Overall survival (OS) of different treatment modalities was compared using log rank test in Kaplan Meier curves. Logistic and Cox regressions were performed to identify predictors of OS among cN1 cohorts respectively.

      Result

      We identified 14,934 cN1 patients undergoing curative treatment. Median age was 67 (IQR 59-73) and median tumor size 4.5 cm (IQR 3-6.4). This included 1,040 patients (7%) undergoing neoadjuvant therapy followed by surgery, 4,398 patients (29.4%) undergoing surgery +/- adjuvant therapy, and 9,496 patients (63.6%) undergoing dCRT. Predictors of neoadjuvant therapy were age (OR=0.96,CI=0.95-0.96), white race (OR=1.54,CI=1.23-1.93), year of diagnosis (OR=0.92,CI=0.90-0.94), Charlson Comorbidity Index (CCI)<2 (OR=1.282,CI=1.004-1.637), adenocarcinoma (OR=1.30,CI=1.12-1.51), larger tumor size (OR=1.002,CI=1.001-1.003, and private insurance (OR=1.51, CI=1.29-1.77). Superior OS was achieved following neoadjuvant therapy and surgery (median-OS=42.1±3.4 months) compared to surgery ± adjuvant therapy (38.4±1.5 months, p=0.002). dCRT was associated with the worst survival (18.9± 0.30 months). By MVA, predictors of poor survival in the cohort were older age (HR=1.015,CI=1.012-1.018), male gender (HR=1.20,CI=1.13-1.26), lack of insurance (HR=1.26,CI=1.08-1.46), higher comorbidities (CCI=2, HR=1.29, CI=1.19-1.40), larger tumors (HR=1.002, CI=1.001-1.002), and the use of dCRT (HR=1.75,CI=1.58-1.95).

      Conclusion

      Neoadjuvant therapy followed by surgery is associated with superior survival compared to upfront surgery +/- adjuvant therapy in this large cohort of patients. dCRT, although used most commonly in patients with cN1 disease, demonstrates the worst survival rates.

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    S01 - IASLC CT Screening Symposium: Forefront Advances in Lung Cancer Screening (Ticketed Session) (ID 853)

    • Event: WCLC 2018
    • Type: Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      S01.17 - Session V: Panel Discussion: Next Steps for Lung Screening? (Now Available) (ID 11898)

      10:30 - 11:30  |  Presenting Author(s): Nasser Altorki

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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