Ethical considerations in lung re-transplantation.

PURPOSE OF REVIEW: Patients undergoing re-transplantation constitute a growing proportion of annual lung transplants. It is necessary to consider ethical considerations of re-transplantation in parallel with clinical progress. RECENT FINDINGS: Most clinical data demonstrate patients undergoing re-transplantation have worse survival outcomes; however, there is limited discussion of the ethical principles surrounding re-transplantation. Ethical guidance in re-transplantation trails clinical advancement. SUMMARY: The four-box model offers a valuable framework for assessing the ethical considerations in re-transplantation. This includes an analysis of medical indications, patient preferences, quality-of-life and contextual factors to support the ethical use of scarce donor lungs.

Initial management and outcomes of nonmalignant esophageal perforations: A Nationwide Inpatient Sample analysis.

BACKGROUND: Management of esophageal perforation includes open surgery, minimally invasive surgery, and endoscopic stent placement. This study analyzed initial treatment and the associated short-term outcomes. METHODS: A retrospective study using the National Inpatient Sample between October 2015 and December 2019 identified adults >18 years with esophageal perforation undergoing an initial nonelective esophageal procedure categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement. Patients with esophageal cancer were excluded. Baseline characteristics and the van Walraven-weighted Elixhauser Comorbidity Index were identified. Outcomes included in-hospital mortality and postintervention complications. Univariable and multivariable Cox regression was used to compare in-hospital survival. RESULTS: In total, 3,345 patients met inclusion criteria: the median age was 62 years (interquartile range 50-72 years), and 1,310 (39%) were female. Open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%) with no differences in van Walraven-weighted Elixhauser Comorbidity Index or mortality. Patients who underwent minimally invasive surgery had a greater proportion of gastrointestinal complications (P = .006); otherwise, there were no differences in postintervention complications. In total, 380 (11%) patients died and were significantly older, with greater van Walraven-weighted Elixhauser Comorbidity Index, and had more postintervention complications. Univariable Cox regression identified age (hazard ratio 1.95, P < .001), van Walraven-weighted Elixhauser Comorbidity Index (hazard ratio 1.06, P < .001), stent placement (hazard ratio 1.93, P = .045), and transfer from a health facility (HR 2.40, P = .049) as associated with decreased in-hospital survival. Multivariable Cox regression revealed age (hazard ratio 1.041, P < .001) and van Walraven-weighted Elixhauser comorbidity index (hazard ratio 1.055, P < .001) were associated with decreased in-hospital survival. CONCLUSION: Patients with esophageal perforation had an 11% in-hospital mortality rate and significant associated complications regardless of intervention. Increasing age and comorbidities are associated with poorer in-hospital survival.

Association between underweight status and chylothorax after esophagectomy for esophageal cancer: A propensity score-matched analysis.

Objective: To use a nationwide database of hospitalizations to investigate underweight status as a risk factor for postesophagectomy complications. Methods: We identified all patients who underwent esophagectomy with a diagnosis of esophageal cancer and known body mass index in the 2018-2020 Nationwide Readmissions Database. All hospital visits for esophagectomy and within 30 days of initial discharge were analyzed for postoperative complications, including chylothorax. Patients who were underweight were propensity score matched with patients who were not. Multivariable logistic regression was performed to identify complications that were significantly associated with underweight status. Results: There were 1877 patients with esophageal cancer meeting inclusion criteria. Following propensity score matching, 433 patients who were underweight were matched to 433 patients who were not. In the multivariable model of the matched sample, which adjusted for age, sex, Charlson Comorbidity Index, history of chemotherapy or radiation therapy, and preoperative surgical feeding access, patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% confidence interval [CI], 1.07-4.25, P = .035). Underweight status was also significantly associated with acute bleed (odds ratio [OR], 1.52; 95% CI, 1.12-2.05, P = .007), pneumothorax (OR, 2.33; 95% CI, 1.19-4.85; P = .017), pneumonia (OR, 2.30; 95% CI, 1.53-3.50, P < .001), and in-hospital mortality (OR, 2.42; 95% CI, 1.31-4.69, P = .006). Conclusions: Underweight status was found to be a risk factor for chylothorax after esophagectomy, which may have implications for perioperative care of esophageal cancer patients. Future studies should assess whether using feeding tubes or total parenteral nutrition preoperatively or thoracic duct ligation intraoperatively decreases risk of chylothorax among patients who were underweight.

Decision-Making in Surgery.

Surgeons face unique challenges in perioperative decision-making and communication with patients and families. In cardiothoracic surgery, the stakes are high, life and death decisions must be made quickly, and surgeons often lack a longstanding relationship with patients and families prior to intervention. This review considers specific challenges in the preoperative period followed by those faced postoperatively. While preoperative deliberation and informed consent focus on reaching a decision between 2 or more alternative approaches, the most vexing postoperative decisions often involve the patient's discontent with the best-case outcome or how to ensure goal-concordant care when complications arise. This review explores the preoperative ethical and legal requirement for informed consent by describing the contemporary preferred method, shared decision-making. We also present a framework to optimize surgeon communication and promote patient and family engagement in the setting of high-risk surgery for older patients with serious illness. In the postoperative period the family is often tasked with deciding what to do about major complications when the patient has lost decision-making capacity. We discuss several examples and offer strategies for surgeons to navigate these challenging situations. We also explore the concepts of clinical heroism and futility in relation to communicating with patients and families about the outcomes of surgery. Persistent ethical challenges in decision-making suggest that surgeons should improve their skills in communicating with patients to better engage with them, both before and after surgery.

Delayed esophagectomy for adenocarcinoma is associated with a negative impact on long-term survival and an increased risk of perioperative morbidity.

OBJECTIVE: Delayed esophagectomy (DE) following chemoradiation therapy (CXRT) for esophageal carcinoma is undertaken in selected patients. This study aimed to assess both short-term outcomes and long-term survival for patients with adenocarcinoma undergoing DE. METHODS: The National Cancer Database was queried for patients with American Joint Committee on Cancer clinical stage II-III esophageal adenocarcinoma undergoing esophagectomy after CXRT. Patients were categorized as (1) DE, ≥90 days between completion of CXRT and surgery or (2) nondelayed esophagectomy (NDE), <90 days. Cox regression was performed to identify factors associated with mortality. RESULTS: A total of 8157 patients met criteria. Age >69, nonwhite race, Medicare/Medicaid insured patients preferentially underwent DE. Five-year overall survival (OS) favored NDE (36% vs. 31%, p = 0.008). Cox regression identified DE, clinical stage >T2, or >N0 as factors associated with mortality. Within the DE group, OS favored early cT-status. DE fared worse than NDE in 30- and 90-day mortality (4.5%/11.1% vs. 2.9%/6.5%, p < 0.01/p < 0.001) and margin positive resection (7.1% vs. 4.2%, p < 0.001). CONCLUSIONS: For esophageal adenocarcinoma, DE is associated with decreased OS compared to NDE. For DE, cT-status is prognostic for OS, while cN-status was not. Increased 30-/90-day mortality and margin positive resection rates for DE question whether patients with locally advanced (cT3/T4) primary esophageal adenocarcinoma should undergo intentional DE.

Longer hospitalizations, more complications, and greater readmissions for patients with comorbid psychiatric disorders undergoing pulmonary lobectomy.

OBJECTIVE: To examine the influence of comorbid psychiatric disorders (PSYD) on postoperative outcomes in patients undergoing pulmonary lobectomy. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2016 to 2018 was performed. Patients with lung cancer with and without psychiatric comorbidities who underwent pulmonary lobectomy were collated and analyzed (International Classification of Diseases, 10th Revision, Clinical Modification Mental, Behavioral and Neurodevelopmental disorders [F01-99]). The association of PSYD with complications, length of stay, and readmissions was assessed using a multivariable regression analysis. Additional subgroup analyses were performed. RESULTS: A total of 41,691 patients met inclusion criteria. Of these, 27.84% (11,605) of the patients had at least 1 PSYD. PSYD was associated with a significantly increased risk of postoperative complications (relative risk, 1.041; 95% CI, 1.015-1.068; P = .0018), pulmonary complications (relative risk, 1.125; 95% CI, 1.08-1.171; P < .0001), longer length of stay (PSYD mean, 6.79 days and non-PSYD mean, 5.68 days; P < .0001), higher 30-day readmission rate (9.2% vs 7.9%; P < .0001), and 90-day readmission rate (15.4% vs 12.9%; P < .007). Among patients with PSYD, those with cognitive disorders and psychotic disorders (eg, schizophrenia) appear to have the highest rates and risks of postoperative morbidity and in-hospital mortality. CONCLUSIONS: Patients with lung cancer with comorbid psychiatric disorders undergoing lobectomy experience worse postoperative outcomes with longer hospitalization, increased rates of overall and pulmonary complications, and greater readmissions suggesting potential opportunities for improved psychiatric care during the perioperative period.

Delays to surgery and worse outcomes: The compounding effects of social determinants of health in non-small cell lung cancer.

Objective: To quantify the compounding effects of social determinants of health on time to surgery (T2S) and clinical outcomes. Methods: The National Cancer Database was queried for treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer undergoing (bi)lobectomy or pneumonectomy between 2006 and 2016 with 1 to 180 days T2S, the number of days between diagnosis and surgery; surgical delays were defined as statistically significant increased T2S compared with a reference cohort. Social determinants of health factors prognostic for surgical delays were identified using multivariable regression. The 30-/90-day mortality and 5-year survival estimates were calculated using logistic and Cox regressions, respectively. Results: In total, 110,005 patients met inclusionary criteria. Multivariable analysis identified race, insurance, and facility type as factors with significant 3-way interaction: T2S of one depended on the others. Income and education also contributed to delays. Privately insured (private) non-Hispanic White patients at academic medical centers (AMCs) were the reference with T2S of 44.1 days. At AMCs, private Black patients had significant delays to surgery (54.7 days; P < .0001), as did Medicaid and uninsured Black patients (58.5 days; P < .0001, 59.4 days; P < .0001, respectively). The 15-day surgical delays were associated with statistically significant 5% increased 30-day mortality odds (confidence interval [CI], 1.03-1.08), 6% increased 90-day mortality odds (CI, 1.04-1.08), and 4% decrease in hazard of death at 5 years (CI, 1.04-1.05). Conclusions: In treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer, Black race, Medicaid, uninsured status, and AMCs generate compounding surgical delays with increased 30-/90-day mortality and decreased 5-year survival. Thoracic surgeons can leverage these facility and demographic-specific insights to standardize time to surgery and begin mitigating underlying disparities.

Early outcomes of lung transplantation with lung allografts from coronavirus disease 2019 (COVID-19)-positive donors.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) can be detected for extended periods of time with nucleic acid amplification test even after transmissibility becomes negligible. Lung allografts from COVID-19-positive donors have been used for transplantation in highly selected cases. This study aimed to clarify the early outcomes of lung transplantation with COVID-19-positive donors. METHODS: The Organ Procurement and Transplantation Network/United Network for Organ Sharing database between April 2020 and June 2022 was retrospectively analyzed. RESULTS: In the study period, 1297 COVID-19-positive donors were identified and the lungs were transplanted from 47 donors (3.6%). Of 47 donors, 44 donors were positive for COVID-19 NAT with nasopharyngeal swabs and the other 3 were positive with bronchoalveolar lavage. The COVID-19-positive lung donors were younger than the COVID-19-negative donors (28.4 ± 11.6 years vs 35.4 ± 13.6 years, P < .001). Recipients of the COVID-19-positive lungs (n = 47) were more likely have a greater lung allocation score (57.1 ± 22.9 vs 50.5 ± 19.7, P = .057) than recipients of COVID-19-negative lungs (n = 5501). The posttransplant length of hospital stay (39.8 ± 43.6 days vs 30.6 ± 34.5 days, P = .181), need for extracorporeal membrane oxygenation support at 72 hours after transplantation (2.6% [1/38] vs 10.4% [541/5184], P = .18), and 1-year overall survival rate (85.6% vs 87.1%, P = .63) were comparable between the 2 groups. CONCLUSIONS: Carefully selected lung allografts from COVID-19-positive donors had comparable early posttransplant outcomes to lung allografts from COVID-19-negative donors.

Adjuvant chemotherapy, not radiotherapy, prolongs survival for node-negative non-small cell lung cancer with positive surgical margins.

Objective: The study objective was to determine differences in survival depending on adjuvant therapy type, timing, and sequence in node-negative disease with positive margins after non-small cell lung cancer resection. Methods: The National Cancer Database was queried for patients with positive margins after surgical resection of treatment-naïve cT1-4N0M0 pN0 non-small cell lung cancer who underwent adjuvant radiotherapy or chemotherapy from 2010 to 2016. Adjuvant treatment groups were defined as surgery alone, chemotherapy alone, radiotherapy alone, concurrent chemoradiotherapy, sequential chemotherapy then radiotherapy, and sequential radiotherapy then chemotherapy. The impact of adjuvant radiotherapy initiation timing on survival was evaluated using multivariable Cox regression. Kaplan-Meier curves were generated to compare 5-year survival. Results: A total of 1713 patients met inclusion criteria. Five-year survival estimates differed significantly between cohorts: surgery alone, 40.7%; chemotherapy alone, 47.0%; radiotherapy alone, 35.1%; concurrent chemoradiotherapy, 45.7%; sequential chemotherapy then radiotherapy, 36.6%; and sequential radiotherapy then chemotherapy, 32.2% (P = .033). Compared with surgery alone, adjuvant radiotherapy alone had a lower estimated survival at 5 years, although overall survival did not differ significantly (P = .8). Chemotherapy alone improved 5-year survival compared with surgery alone (P = .0016) and provided a statistically significant survival advantage over adjuvant radiotherapy (P = .002). Compared with radiotherapy-inclusive multimodal therapies, chemotherapy alone yielded similar 5-year survival (P = .066). Multivariable Cox regression showed an inverse linear association between time to adjuvant radiotherapy initiation and survival, but with an insignificant trend (10-day hazard ratio, 1.004; P = .90). Conclusions: In treatment-naïve cT1-4N0M0 pN0 non-small cell lung cancer with positive surgical margins, only adjuvant chemotherapy was associated with a survival improvement compared with surgery alone, with no radiotherapy-inclusive treatment providing additional survival benefit. Delayed timing of radiotherapy initiation was not associated with a survival reduction.

Centers for Disease Control (CDC) Wound Classification is Prognostic of 30-Day Readmission Following Surgery.

BACKGROUND: The goal of this study was to investigate factors associated with 30-day readmission in a multivariate model, including the CDC wound classes "clean," "clean/contaminated," "contaminated," and "dirty/infected." METHODS: The 2017-2020 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients undergoing total hip replacement, coronary artery bypass grafting, Ivor Lewis esophagectomy, pancreaticoduodenectomy, distal pancreatectomy, pneumonectomy, and colectomies. ACS-defined wound classes were concordant with CDC definitions. Multivariate linear mixed regression was used to determine risk factors for readmission while adjusting for type of surgery as a random intercept. RESULTS: 477,964 cases were identified, with 38,734 (8.1%) patients having experienced readmission within 30 days of surgery. There were 181,243 (37.9%) cases classified as wound class "clean", 215,729 (45.1%) cases classified as "clean/contaminated", 40,684 cases (8.5%) classified as "contaminated", and 40,308 (8.4%) cases classified as "dirty/infected". In the multivariate generalized mixed linear model adjusting for type of surgery, sex, body mass index, race, American Society of Anesthesiologists class, presence of comorbidity, length of stay, urgency of surgery, and discharge destination, "clean/contaminated" (p < .001), "contaminated" (p < .001), and "dirty/infected" (p < .001) wound classes (when compared to "clean") were significantly associated with 30-day readmission. Organ/space surgical site infection and sepsis were among the most common reasons for readmission in all wound classes. CONCLUSIONS: Wound classification was strongly prognostic for readmission in multivariable models, suggesting that it may serve as a marker of readmissions. Surgical procedures that are "non-clean" are at significantly greater risk for 30-day readmission. Readmissions may be due to infectious complications; optimizing antibiotic use or source control to prevent readmission are areas of future study.

Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model.

OBJECTIVE: The study objective was to develop a generalizable financial model that estimates payor-specific reimbursements associated with anatomic lung resections for any hospital-based thoracic surgery practice. METHODS: Medical records of patients who presented to the thoracic surgery clinic and eventually underwent an anatomic lung resection from January 2019 to December 2020 were reviewed. The volume of preoperative and postoperative studies, clinic visits, and outpatient referrals was measured. Neither subsequent studies nor procedures from outpatient referrals were captured. Diagnosis-related group, cost-to-charge ratios, Current Procedural Terminology Medicare payment data, and Private:Medicare and Medicaid:Medicare payment ratios were used to estimate payor-specific reimbursements and operating margin. RESULTS: A total of 111 patients met inclusion criteria and underwent 113 operations: 102 (90%) lobectomies, 7 (6%) segmentectomies, and 4 (4%) pneumonectomies. These patients underwent 554 total studies, received 60 referrals to other specialties, and had 626 total clinic visits. The total charges and Medicare reimbursement were $12.5 M and $2.7 M, respectively. After adjusting for a 41% Medicare, 2% Medicaid, and 57% Private payor mix, the total reimbursement was $4.7 M. With a 0.252 cost-to-charge ratio, total costs and operating income were $3.2 M and $1.5 M, respectively (ie, 33% operating margin). Average reimbursement per surgery by payor was $51k for Private, $29k for Medicare, and $23k for Medicaid. CONCLUSIONS: For any hospital-based thoracic surgery practice, this novel financial model can calculate both overall and payor-specific reimbursements, costs, and operating margin across the full perioperative spectrum. By manipulating hospital name, hospital state, volume, and payor mix, any program can gain insights into their financial contributions and use the outputs to guide investment decisions.

Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non-small cell lung cancer.

OBJECTIVE: The objective of this study was to evaluate the feasibility of minimally invasive surgery (MIS) and perioperative outcomes following neoadjuvant immunotherapy for resectable non-small cell lung cancer (NSCLC). METHODS: Patients with stage I to III NSCLC treated with immunotherapy with or without chemotherapy or chemotherapy alone prior to lobectomy were identified in the National Cancer Database (2010-2018). The percentage of operations performed minimally invasively, conversion rates, and perioperative outcomes were evaluated using propensity-score matching. Propensity-score matching was also used to compare perioperative outcomes between patients who underwent an open lobectomy and those who underwent an MIS lobectomy after neoadjuvant immunotherapy. RESULTS: Of the 4229 patients identified, 218 (5%) received neoadjuvant immunotherapy and 4011 (95%) received neoadjuvant chemotherapy alone. There was no difference in the rate of MIS lobectomy among patients who received immunotherapy compared with those who received chemotherapy alone in propensity score-matched analysis (60.8% vs 51.6%; P = .11). There also were no significant differences in the rate of conversion from MIS to open lobectomy (14% vs 15%, P = .83; odds ratio, 1.1; 95% confidence interval, 0.51-2.24) or in nodal downstaging, margin positivity, 30-day readmission, and 30- and 90-day mortality between the 2 groups. In a subgroup analysis of only patients treated with neoadjuvant immunotherapy, there were no differences in pathologic or perioperative outcomes between patients who underwent open lobectomy and those who underwent MIS lobectomy. CONCLUSIONS: In this national analysis, neoadjuvant immunotherapy for resectable NSCLC was not associated with an increased likelihood of the need for thoracotomy, conversion from MIS to open lobectomy, or inferior perioperative outcomes.

Heart transplantation for pediatric foreign nationals in the United States.

BACKGROUND: This study aimed to clarify survival outcomes, waitlist mortality, and waitlist days of heart transplantation of pediatric foreign nationals compared to pediatric United States (US) citizens. METHODS: We retrieved data from March 2012 to June 2021 in the United Network Organ Sharing (UNOS) registry. RESULTS: Of 5857 pediatric patients newly waitlisted, 133 (2.27%) patients were non-US citizen/non-US residents (non-citizen non-resident [NCNR]). Patients with congenital heart disease were higher in the US citizen group than in the NCNR group (51.9% vs. 22.6%, p < .001); 76.7% of patients in the NCNR group (102/133) had cardiomyopathy. Of the 133 NCNRs, 111 patients (83.5%) underwent heart transplantation, which was significantly higher than that in the US citizen group (68.6%, p < .001). The median waitlist time was 71 days (IQR, 22-172 days) in the NCNR group and 74 days (29-184 days) in the US citizen group (p = .48). Survival after heart transplant was significantly better in the NCNR group than in the US citizen group (n = 3982; logrank test p = .015). CONCLUSIONS: Heart transplantation for pediatric foreign nationals was mostly indicated for cardiomyopathy, and their transplant rate was significantly higher than that in the US citizen group, with better survival outcomes. The better survival outcomes in the NCNR group compared to the US citizen group can likely be attributed to the differing diagnoses for which transplantation was performed.

Benefit of adjuvant chemotherapy for resected pathologic N1 non-small cell lung cancer is unrecognized: A subgroup analysis of the JBR10 trial.

Adjuvant chemotherapy is underutilized in clinical practice, in part, because its anticipated survival benefit is limited. We evaluated the impact of AC on overall and recurrence-free survival among completely resected pN1 NSCLC patients enrolled in the North American Intergroup phase III (JBR10) trial. A post-hoc subgroup analysis of pN1 NSCLC patients was performed. Participants were randomized to cisplatin+vinorelbine (AC) (n = 118) or observation (n = 116) following complete resection. The primary endpoint was overall survival (OS). The secondary endpoint was recurrence free survival (RFS). Kaplan-Meier methods were used to compare OS and RFS between the two treatment groups. Cox regression was used to identify factors associated with OS and RFS endpoints. Both groups had similar baseline characteristics. AC patients had improved 5-year OS (AC 61.4% vs observation 41.0%, log-rank p = .008) and 5-year RFS (AC 56.2% vs observation 39.9%, log-rank p = .011) rates compared to observation. Cox regression analyses confirmed the OS (HR 0.583, 95% CI 0.402-0.846, p = .005) and RFS (HR 0.573, 95% CI 0.395-0.830, p = .003) benefit associated with AC. AC was associated with a lower risk (HR 0.648, 95% CI 0.435-0.965, p = .0326) and a lower cumulative incidence (Subdistribution Hazard Ratio [SHR], 0.67, 95% CI 0.449-0.999, p = .0498) of lung cancer deaths. In the JBR10 trial, treatment with AC conferred a significant OS and RFS advantage over observation for pN1 NSCLC patients. These data suggest that pN1 NSCLC patients may experience a disproportionately greater clinical benefit from AC than the 6% survival advantage estimated by the LACE meta-analysis.

Surgical decision-making in advanced-stage non-small cell lung cancer is influenced by more than just guidelines.

Objective: This qualitative study sought to uncover factors that influence decisions to offer curative-intent surgery for patients with advanced-stage (stage IIIB/IV) non-small cell lung cancer. Methods: A trained interviewer conducted open-ended, semistructured telephone interviews with cardiothoracic surgeons in the United States. Participants were recruited from the Thoracic Surgery Outcomes Research Network, with subsequent diversification through snowball sampling. Four hypothetical clinical scenarios were presented, each demonstrating varying levels of ambiguity with respect to international guideline recommendations. Interviews continued until thematic saturation was reached. Interview transcripts were coded using inductive reasoning and conventional content analysis. Results: Of the 27 participants, most had been in practice for ≤20 years (n = 23) and were in academic practice (n = 18). When considering nonguideline-concordant surgeries, participants were aware of relevant guidelines but acknowledged their limitations for unique scenarios. Surgeons perceived that a common barrier to offering surgery is incomplete nonsurgeon physician understanding of surgical capabilities or expected morbidity; and that improved education is necessary to correct these misperceptions. Surgeons expressed concern that undertaking a controversial resection for an individual patient could fracture trust built in long-term professional relationships. Surgeons may face pressure from patients to operate despite a low expectation of clinical benefit, leading to emotional turmoil for the patient and surgeon. Conclusions: This qualitative study generates the hypothesis that the scope of current guidelines, availability of clinical trial protocols, perceived surgical knowledge among nonsurgeon colleagues, interprofessional relationships, and emotional pressure all influence a surgeon's willingness to offer curative-intent surgery for patients with advanced-stage non-small cell lung cancer.

Lobectomy offers improved survival outcomes relative to segmentectomy for >2 but ≤4 cm non-small cell lung cancer tumors.

Objective: The objective was to compare overall survival (OS) between lobectomy and segmentectomy for patients with non-small cell lung cancers (NSCLCs) > 2 but ≤4 cm. Methods: The National Cancer Database was queried to identify treatment-naïve patients with NSCLC tumors >2 but ≤4 cm. Eligible patients were diagnosed with pT1 or T2 N0 M0 disease, underwent lobectomy or segmentectomy, and received no adjuvant therapy. OS was compared using the Kaplan-Meier method, and the Cox proportional-hazards model was used to identify prognostic factors for death. Propensity score matching was performed to minimize the effects of potential confounders. Results: Included were 32,792 patients: lobectomy (n = 31,353) and segmentectomy (n = 1439). Five-year OS was improved following lobectomy over segmentectomy for patients with >2 but ≤4 cm NSCLCs (62.3% vs 52.6%; P < .0001). Further stratification demonstrated improved 5-year OS following lobectomy over segmentectomy: >2 but ≤3 cm (64.9% vs 54.3%; P < .0001) and >3 but ≤4 cm (56.9% vs 47.6%; P = .0003). In patients with a Charlson-Deyo comorbidity index of 0, 5-year OS was greater following lobectomy for >2 but ≤4 cm tumors (67.1% vs 62.1%; P = .03). Further stratification demonstrated improved 5-year OS following lobectomy for patients with Charlson-Deyo comorbidity index of 0 and > 3 but ≤4 cm tumors (61.8% vs 54.6%; P = .02). Segmentectomy was prognostic for increased risk of death in the year 1 through 5 postoperative period (hazard ratio, 1.35; P < .0001). Five-year OS remained greater following lobectomy after propensity score matching (59.6% vs 52.7%; P = .02). Conclusions: Lobectomy is associated with superior 5-year OS compared with segmentectomy and may be preferred for NSCLC tumors >2 but ≤4 cm when feasible.