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Y. Lee



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    P1.01 - Poster Session with Presenters Present (ID 453)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Epidemiology/Tobacco Control and Cessation/Prevention
    • Presentations: 2
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      P1.01-021 - The Impact of Smoking Status on Overall Survival in a Population-Based Non-Small Cell Lung Cancer (NSCLC) Surgical Resection Cohort (ID 5732)

      14:30 - 14:30  |  Author(s): Y. Lee

      • Abstract
      • Slides

      Background:
      Surgical resection is the optimal treatment modality for NSCLC, while smoking has been shown to have a negative survival impact. We evaluated smoking’s impact on overall survival within a population-based cohort of patients with surgically-resected NSCLC.

      Methods:
      We examined all patients who had a curative-intent NSCLC resection from 2009-2016 in 4 contiguous Dartmouth Hospital Referral Regions of the US. We compared patient and clinical characteristics among never, former (stopped >1 year prior), and active smokers using the Chi-square and ANOVA tests. Survival analyses were conducted with the Kaplan-Meier method and Cox Proportional Hazards models.

      Results:
      Of 2,202 patients, 206 (9%) were never, 846 (38%) were former, and 1,150 (52%) were active smokers. Significant demographic and clinical differences between cohorts included age, sex, race, insurance, comorbidities, pulmonary function, method of detection, ASA status, extent, primary site and length of resection, histology, and histologic grade (all p<0.05). Short-term post-operative mortality (at 30-, 60-, 90-, 120-days) rates for never smokers were 1%, 2%, 4%, 4%; for active smokers, 4%, 6%, 7% and 8%; and for former smokers, 5%, 7%, 9%, and 11%; and differed significantly by smoking status (p=0.0539, p=0.0316, p=0.0187, p=0.0017). At 5 years, overall survival was 69% for never smokers, 55% for active, and 49% for former smokers (p=0.0002) (Figure 1). Controlling for age, sex, race, insurance, histologic grade, extent of resection, and length of surgery, and compared with never smokers, active smokers had 1.3 times (p=0.05) the hazard of death and former smokers had 1.4 times the hazard of death (p=0.04). Figure 1



      Conclusion:
      In this population-based cohort, smoking is negatively associated with post-operative mortality and long-term overall patient survival; although active smokers had better survival outcomes than former smokers.

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      P1.01-030 - Factors Associated with Margin Positive Resections for Non-Small Cell Lung Cancer (NSCLC) in the Mid-South Region of the US (ID 5076)

      14:30 - 14:30  |  Author(s): Y. Lee

      • Abstract
      • Slides

      Background:
      Incomplete resection of NSCLC has a negative impact on survival. We evaluated risk factors associated with positive margins within a comparative observational population-based cohort study.

      Methods:
      We analyzed curative-intent resections from 2009-2016 from 4 contiguous Dartmouth Hospital Referral Regions in 3 US states. Statistical analyses were preformed using univariate and multiple logistic regression models.

      Results:
      Among the 2,275 NSCLC-resected patients, 52% were male, 78% white, 45% Medicare insured, and 36% privately insured, with a median age of 67 years. Factors associated with a higher margin positivity rate included male sex, large cell histology, undifferentiated tumor grade, neo-adjuvant therapy, clinical stage IIIA and IIIB, bilobectomy extent of resection, patients with abnormal diffusing capacity of the lungs for carbon monoxide (DLCO), use of bronchoscopic biopsy for diagnosis greater than 1 day before surgery, left lung resection, and tumor size >7cm (all p<0.15, Table 1). American Society of Anesthesiologists (ASA) score, prior lung cancer, smoking status, Charlson score, FEV1, PET/CT, brain scan, bone scan, mediastinoscopy, blood transfusion, and hospital were not associated with positive margins in univariate analyses (all p>0.15). Controlling for sex, histology, tumor grade, tumor size, neo-adjuvant therapy, clinical stage, extent of resection, DLCO, pre-operative bronchoscopic biopsy, and primary resection site in the multiple variable analysis, sex (p=0.0134), clinical stage (p<0.001), extent of resection(p=0.0461), DLCO (p=0.0431), and bronchoscopic biopsy (p=0.0029) were independently associated with risk for positive margins (Table 1).

      Conclusion:
      This detailed evaluation in a large regional cohort indicates patient-level characteristics are associated with positive surgical resection margins. Our recently published evaluation of the National Cancer Database also identified institutional factors that impact the rates of positive margins. Patient-level, surgeon-level, and institutional-level factors should be considered jointly to fully understand factors impacting margin positivity rates. Figure 1



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    P1.03 - Poster Session with Presenters Present (ID 455)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      P1.03-067 - Validation of the IASLC 8th Edition (8E) TNM Classification for Non-Small Cell Lung Cancer by the Quality of Surgical Resection in a US Cohort (ID 6237)

      14:30 - 14:30  |  Author(s): Y. Lee

      • Abstract

      Background:
      We compared the prognostic impact of 8E to 7[th] Edition(7E), using sequentially-defined surgical quality cohorts.

      Methods:
      We analyzed curative-intent resections for non-small cell lung cancer from 2009-2016 in a population based cohort from 4 Dartmouth Referral Regions in 3 US states. Patients were re-staged by 8E criteria. Survival analyses used Kaplan-Meier estimates and Proportional Hazards models with adjusted hazard ratios(aHR) controlling for age, histology, grade, and comorbidities.

      Results:
      548 of 2226 patients were stage-redistributed: 525(24%) up, 23(1%) down-staged. The largest shifts were from IB to IIA (76/522 [15%]);IIA to IIB (238/251[95%]); IIB to IIIA (88/217 [41%]); IIIA to IIIB (59/277[21%]). We found no difference in unadjusted survival in patients upstaged to IIA compared with those remaining in IB (p=0.55). Patients upstaged from IIB to IIIA had similar survival to those remaining IIB (p=0.4884), but were similar to patients already IIIA by 7E (p=0.8152). However, patients upstaged from IIIA to IIIB had worse survival than those remaining in IIIA (p=0.0360). Sub-classification of IA had no prognostic value when comparing IA1 vs. IA2 (p=0.74), but patients in IA3 had significantly worse survival than those in IA2 (p=0.0177). 5-year survival estimates for IA1/IA2/IA3 were 65%, 68%, and 61% in our cohort, compared to 92%, 83%, and 77% in the IASLC database. Adjusted models indicate 8E stage as a significant prognostic factor (p<0.0001), with increasing hazards of death with each progressive stage beyond IA2 (Table 1). This result was reasonably consistent as the quality of resection increased incrementally from: All Patients, excluding margin-positives, excluding margin-positives and pNX resections, excluding margin-positives and resections without mediastinal nodes(MedNX).

      IASLC 8th-EditionStage 3-Year SurvivalEstimate (95% CI) 5-Year SurvivalEstimate (95% CI)
      IA1(N=91) 0.80(0.69-0.88) 0.65(0.48-0.77)
      IA2(N=454) 0.80(0.75-0.84) 0.68(0.62-0.73)
      IA3(N=312) 0.71(0.65-0.76) 0.61(0.54-0.68)
      IB(N=509) 0.67(0.63-0.72) 0.55(0.49-0.60)
      IIA(N=81) 0.66(0.53-0.76) 0.61(0.48-0.72)
      IIB(N=375) 0.59(0.53-0.64) 0.45(0.39-0.52)
      IIIA(N=302) 0.50(0.43-0.56) 0.41(0.34-0.48)
      IIIB(N=62) 0.39(0.26-0.52) 0.29(0.18-0.42)
      IV(N=40) 0.44(0.26-0.61) 0.44(0.26-0.61)
      Adjusted Hazard Ratios by Quality Parameters
      All Patients (N=2195) Exclude Margin+ (N=2090) Exclude Margin+/pNX (N=1939) Exclude Margin+/MedNX (N=1656)
      IA1 1.00 1.00 1.00 1.00
      IA2 0.83 0.83 0.70 0.75
      IA3 1.12 1.11 1.00 1.13
      IB 1.30 1.26 1.11 1.23
      IIA 1.34 1.27 1.11 1.25
      IIB 1.72 1.69 1.56 1.69
      IIIA 2.40 2.31 2.11 2.45
      IIIB 3.73 3.21 2.95 3.41
      IV 3.76 3.43 2.62 3.11


      Conclusion:
      8E was generally supported by our data, although modifications for Stage IA1-IIB patients were not fully evident, even in high-quality resections. The survival disparity with IASLC data suggests that unidentified confounding factors are impairing survival in this early-stage US NSCLC cohort.