Estimating the Impact of Extended Delay to Surgery for Stage I Non-Small-Cell Lung Cancer on Survival: Lessons for the COVID-19 Pandemic.

Mayne, Nicholas R; Elser, Holly; Darling, Alice J; Raman, Vignesh; Liou, Douglas; Colson, Yolonda; D'Amico, Thomas A; Yang, Chi-Fu Jeffrey

OBJECTIVE. The purpose of this study is to evaluate the impact of extended delay to surgery for stage I non-small-cell lung cancer (NSCLC). SUMMARY BACKGROUND DATA. During the COVID-19 pandemic, patients with NSCLC may experience delays in care, and some national guidelines recommend delays in surgery by >3 months for early NSCLC. METHODS. Using data from the National Lung Screening Trial (NLST), a multi-center randomized trial, and the National Cancer Data Base (NCDB), a multi-institutional oncology registry, the impact of "early" versus "delayed" surgery (surgery received 0-30 versus 90-120 days following diagnosis) for stage I lung adenocarcinoma and squamous cell carcinoma was assessed using multivariable Cox regression analysis with penalized smoothing spline functions and propensity score-matched analyses. RESULTS. In Cox regression analysis of the NLST (n = 452) and NCDB (n = 80,086) cohorts, an increase in the hazard ratio (HR) was seen the longer surgery was delayed. In propensity score-matched analysis, no differences in survival were found between early and delayed surgery for stage IA1 adenocarcinoma and IA1-IA3 squamous cell carcinoma (all P > 0.13). For stage IA2-IB adenocarcinoma and IB squamous cell carcinoma, delayed surgery was associated with worse survival (all P < 0.004). CONCLUSIONS. The mortality risk associated with an extended delay to surgery differs across patient subgroups, and decisions to delay care during the COVID pandemic should take substage and histologic subtype into consideration. For stage IA1 adenocarcinoma and IA squamous cell carcinoma, delaying surgery may be considered; however, for IA2-IB adenocarcinoma and IB squamous cell carcinoma, early surgery-when feasible-should be encouraged.