Disparities in Guideline-Concordant Treatment for Node-positive Non-Small Cell Lung Cancer Following Surgery

Abstract Objectives The purpose of this study was to examine guideline concordance across a national sample and determine the relationship between socioeconomic factors, use of recommended post-operative adjuvant therapy, and outcomes for patients with resected pN1 or pN2 non-small cell lung cancer (NSCLC). Methods All margin-negative pT1-3 N1-2 M0 NSCLC treated with lobectomy or pneumonectomy without induction therapy in the National Cancer Database between 2006-2013 were included. Use of guideline-concordant adjuvant treatment, defined as chemotherapy for pN1 disease and chemotherapy with or without radiation for pN2 disease, was examined. Multivariable regression models were developed to determine associations of clinical factors with guideline adherence. Survival was estimated using Kaplan-Meier and Cox proportional hazard analyses. Results Of 13,462 patients, 10,113 had pN1 disease and 3,349 had pN2 disease. Guideline-concordant adjuvant therapy was utilized in 6,844 (67.7%) pN1 patients and 2,622 (78.3%) pN2 patients. After multivariable adjustment, insurance status, older age, pneumonectomy, readmission and longer post-operative stays were associated with lower likelihood of guideline concordance. Conversely, increased education level, later year of diagnosis and higher nodal stage were associated with higher concordance. Overall, patients treated with guideline-concordant therapy had superior survival (5-year survival: 51.6 vs. 36.0%; Hazard ratio: 0.66, 95% Confidence Interval: 0.62-0.70, p Conclusions Socioeconomic factors, including insurance status and geographic region, are associated with disparities in use of adjuvant therapy as recommended by National Comprehensive Cancer Network guidelines. These disparities significantly impact patient survival. Future work should focus on improving access to appropriate adjuvant therapies among the under insured and socioeconomically disadvantaged.