Changes in treatment patterns and survival in elderly patients with stage I non–small-cell lung cancer with the introduction of stereotactic body radiotherapy and video-assisted thoracic surgery

Background: The optimal treatment of elderly patients with early-stage non–small-cell lung cancer (NSCLC) remains elusive. Still, the introduction of video-assisted thoracic surgery (VATS) and stereotactic body radiotherapy (SBRT) may have led to more elderly receiving treatment and improved median overall survival (OS).
Materials and methods: We analysed data from the Netherlands Cancer Registry of 2168 patients ≥65 years with clinical stage I NSCLC and distinguished two periods: 2004–2008 (A) and 2009–2013 (B). The analyses focussed on treatment patterns and median OS for patients receiving surgery, radiotherapy or neither surgery nor radiotherapy. Furthermore, we explored the influence of the application of VATS and SBRT.
Results: The resection rate did not differ between the periods A and B (51% versus 53%; p = 0.37), despite significantly more VATS procedures in the latter period (0% versus 32%; p < 0.001). Application of radiotherapy increased (26% versus 33%; p = 0.001), especially SBRT (3% versus 63%; p < 0.001). The proportion of patients receiving neither therapy decreased (23% versus 14%; p < 0.001). Median OS for all patients significantly improved (31 versus 42 months; p = 0.001), and also for those receiving radiotherapy (23 versus 33 months; p = 0.02), but not significantly for surgical patients (65 versus 74 months; p = 0.16). Still, in multivariable analysis, surgical patients had an increased risk of death in period A compared with period B (hazard ratio [HR] 1.20; 95% confidence interval [CI], 1.01–1.43); this was not the case for patients receiving radiotherapy (HR 1.19; 95% CI, 0.99–1.43). Five-year OS was 57% for surgical patients and 23% for those receiving radiotherapy.
Conclusion: In elderly patients with stage I NSCLC, the use of surgery remained constant, that of radiotherapy increased and fewer patients received neither treatment over the years. Median OS improved for all patients; surgery was associated with the highest long-term OS.