COMPARISON OF GUIDELINE-RECOMMENDED AND PRELIMINARY RISK-BASED APPROACHES TO SELECTION OF LUNG CANCER PATIENTS FOR LYMPH NODE STAGING
Author(s)
SHIVEN BHARDWAJ, PharmD, MAS1, Sarah Rudasill, MD2, Jing Zeng, MD3, Christina Baik, MD4, Sudhakar Pipavath, MD5, Patrick J Heagerty, PhD6, Lori Sakoda, PhD, MPH7, Douglas E. Wood, MD2, Jeffrey B. Velotta, MD8, Gerard A. Silvestri, MD, MS9, Michael K Gould, MD, MS10, Robert Greenlee, PhD11, David Veenstra, PharmD, PhD1, Farhood Farjah, MD, MS2;
1University of Washington School of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Seattle, WA, USA, 2University of Washington School of Medicine, Department of Surgery, Seattle, WA, USA, 3University of Washington School of Medicine, Department of Radiation Oncology, Seattle, WA, USA, 4University of Washington School of Medicine, Division of Medical Oncology, Seattle, WA, USA, 5University of Washington School of Medicine, Department of Radiology, Seattle, WA, USA, 6University of Washington School of Public Health, Department of Biostatistics, Seattle, WA, USA, 7Kaiser Permanente Northern California, Division of Research, Pleasanton, CA, USA, 8Kaiser Permanente Northern California, Thoracic Surgery, Oakland, CA, USA, 9Medical University of South Carolina, Department of Medicine, Charleston, SC, USA, 10Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA, 11Marshfield Clinic Research Institute, Center for Clinical Epidemiology and Population Health, Marshfield, WI, USA
1University of Washington School of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Seattle, WA, USA, 2University of Washington School of Medicine, Department of Surgery, Seattle, WA, USA, 3University of Washington School of Medicine, Department of Radiation Oncology, Seattle, WA, USA, 4University of Washington School of Medicine, Division of Medical Oncology, Seattle, WA, USA, 5University of Washington School of Medicine, Department of Radiology, Seattle, WA, USA, 6University of Washington School of Public Health, Department of Biostatistics, Seattle, WA, USA, 7Kaiser Permanente Northern California, Division of Research, Pleasanton, CA, USA, 8Kaiser Permanente Northern California, Thoracic Surgery, Oakland, CA, USA, 9Medical University of South Carolina, Department of Medicine, Charleston, SC, USA, 10Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA, 11Marshfield Clinic Research Institute, Center for Clinical Epidemiology and Population Health, Marshfield, WI, USA
OBJECTIVES: Selective use of lymph node biopsy facilitates nodal staging among patients with non-metastatic lung cancer. Recent data indicate that nearly all patients with nodal disease receive a lymph node biopsy per current guidelines, but many without nodal disease are also recommended to receive a lymph node biopsy. A preliminary risk-based approach developed from data on 123 patients aims to reduce avoidable lymph node biopsies by leveraging patient and disease characteristics without affecting overall survival.
METHODS: We developed a decision tree to compare the guideline-recommended nodal staging approach with risk-based nodal staging with a pre-defined minimum clinically important difference of 5% in overall survival. We used five-year overall survival reported in the literature after use of radiation, surgery and systemic therapies. We compared the five-year overall survival and distribution of patients across decision-tree branches, assuming 10,000 individuals treated under each approach.
RESULTS: The 5-year overall survival values were 0.6446 and 0.6438 with risk-based and guideline-recommended approaches, respectively. Among the 10,000 individuals, the largest difference between the two approaches was among those without nodal disease (N0); 1,463 fewer individuals with N0 disease received a lymph node biopsy under the risk-based approach. Overall, 1,537 fewer individuals received biopsy in the risk-based approach. In a one-way sensitivity analysis (OWSA), varying all inputs by ±20% resulted in a range of differences in 5-year overall survival values of -0.002 to 0.0006. The range of differences in number of N0 patients who received a lymph node biopsy was 1,346 to 1,580 in the OWSA.
CONCLUSIONS: Adoption of risk-based algorithms may reduce avoidable lymph node biopsies for patients with lung cancer without any impact on survival. OWSA suggests that neither approach results in better survival compared to the other. Further analyses are necessary to validate these preliminary findings in larger patient populations.
METHODS: We developed a decision tree to compare the guideline-recommended nodal staging approach with risk-based nodal staging with a pre-defined minimum clinically important difference of 5% in overall survival. We used five-year overall survival reported in the literature after use of radiation, surgery and systemic therapies. We compared the five-year overall survival and distribution of patients across decision-tree branches, assuming 10,000 individuals treated under each approach.
RESULTS: The 5-year overall survival values were 0.6446 and 0.6438 with risk-based and guideline-recommended approaches, respectively. Among the 10,000 individuals, the largest difference between the two approaches was among those without nodal disease (N0); 1,463 fewer individuals with N0 disease received a lymph node biopsy under the risk-based approach. Overall, 1,537 fewer individuals received biopsy in the risk-based approach. In a one-way sensitivity analysis (OWSA), varying all inputs by ±20% resulted in a range of differences in 5-year overall survival values of -0.002 to 0.0006. The range of differences in number of N0 patients who received a lymph node biopsy was 1,346 to 1,580 in the OWSA.
CONCLUSIONS: Adoption of risk-based algorithms may reduce avoidable lymph node biopsies for patients with lung cancer without any impact on survival. OWSA suggests that neither approach results in better survival compared to the other. Further analyses are necessary to validate these preliminary findings in larger patient populations.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HSD13
Topic
Health Service Delivery & Process of Care
Disease
SDC: Oncology