Surgery Versus Optimal Medical Management for N1 Small Cell Lung Cancer

Background. Adjuvant chemotherapy has been demonstrated to improve the outcomes of patients with N1 non-small cell lung cancer. It is unknown whether patients previously thought to have unresectable small cell lung cancer (SCLC) may have tumors amenable to surgery if adjuvant therapies can be given. This study was undertaken to evaluate whether surgery, in the setting of modern adjuvant therapies, can be beneficial for patients with N1-positive SCLC. Methods. Patients with clinical T1-3 N1 M0 SCLC who underwent concurrent chemoradiation versus surgery and adjuvant therapy in the National Cancer Data Base from 2003 to 2011 were examined. Overall survival was assessed using Kaplan-Meier and Cox proportional hazards analysis and propensity score-matched analysis. Results. Of 1,041 patients with cT1-3 N1M0 SCLC who met inclusion criteria, 96 patients (9%) underwent surgery and adjuvant chemotherapy with or without radiation and 945 (91%) underwent concurrent chemoradiation alone. Multivariable Cox modeling demonstrated that surgery with adjuvant chemotherapy with or without radiation (hazard ratio 0.74, 95% confidence interval: 0.56 to 0.97) was associated with improved survival compared with concurrent chemoradiation. After propensity matching, surgery with adjuvant chemotherapy with or without radiation was associated with improved 5-year survival compared with concurrent chemoradiation (31.4% versus 26.3%). Conclusions. In an analysis of a national population-based cancer database, surgery followed by adjuvant chemotherapy with or without radiation for cT1-3 N1 SCLC had improved outcomes compared with concurrent chemoradiation. These results support the re-evaluation of the role of surgery in multimodality therapy for N1 SCLC in a clinical trial setting. (C) 2017 by The Society of Thoracic Surgeons