Is Segmentectomy Safe in Elderly Patients with Stage 1A Non-Small Cell Lung Cancer?

Purpose: The results of JCOG0802 suggest segmentectomy as the new standard of care for early-stage non-small cell lung cancers (NSCLC). We sought to determine if segmentectomy would provide a similar benefit, relative to lobectomy, for elderly Americans with small, early-stage NSCLC.

Methods: All patients aged 66 and older with a primary diagnosis of Stage IA (≤ 3cm) NSCLC in the Surveillance Epidemiology End Results (SEER) database from 2007 to 2015 were included for analysis. Patients were stratified by procedure performed (lobectomy, segmentectomy, wedge resection). Overall survival by procedure type was compared via Kaplan Meier survival curve analysis. Cox Regression adjusted for patient demographics, socioeconomic status, cancer-specific characteristics (i.e., tumor size, laterality, histology, and grade), year of cancer diagnosis, primary payer at diagnosis and comorbidities. Sensitivity analyses of procedure-specific survival according to histologic subtype were also performed.

Results: A total of 7189 patients were included for analysis. Median age was 73; 13.6% of patients were aged greater than 80 years. The majority of patients were white [6483; 90.4%], of male sex [3060; 42.6%], and were members of communities with less than 20% poverty [5842, 81.3%]. Of the total cohort, 5130 [71.4%] underwent lobectomy, 441 [6.1%] underwent segmentectomy, and 1618; [22.5%] underwent wedge resection. Median length of follow-up was 67 months. Patients undergoing segmentectomy had significantly lower overall survival, relative to lobectomy (Figure). Cox regression identified significantly higher risk-adjusted hazard of all-cause mortality among patients undergoing segmentectomy relative to lobectomy (HR 1.17, CI 1.03-1.32, p = 0.014). Patients undergoing wedge resection did not have significantly higher risk-adjusted hazard of all-cause mortality relative to those undergoing lobectomy (HR 1.0, CI 0.93-1.08, p = 0.97). Histology subtype sensitivity analyses revealed similar increased risk-adjusted hazard of all-cause mortality for patients with adenocarcinoma who underwent segmentectomy, relative to lobectomy (HR 1.21, CI 1.03 – 1.42, p = 0.02), however no significant difference was observed between segmentectomy and lobectomy among patients with squamous cell carcinoma (HR 1.04, CI 0.78 – 1.39, p = 0.77).

Conclusion: Segmentectomy was associated with higher risk-adjusted hazard of all-cause mortality, relative to lobectomy, for elderly patients with Stage IA NSCLC. These findings suggest the importance of confirming the generalizability of JCOG0802 via a randomized control trial in the United States.

Identify the source of the funding for this research project: This work was funded in part by a grant under Award Number 2UM HL088925, as well as by the National Heart, Lung, and Blood Institute (grant T32 HL007849-21A1).