OBJECTIVES: Conflicting evidence from clinical trials has led to uncertainty about which treatment strategy maximizes quality-adjusted life expectancy for survivors of node-positive Stage III non-small cell lung cancer (NSCLC). This study addresses this uncertainty by comparing the survival benefits as well as the quality-adjusted life expectancy attributable to each strategy. We hypothesized that the strategy that maximizes survival differs from the strategy that maximizes quality-adjusted life expectancy.

METHODS: Systematic review of the literature was conducted to identify clinical trials for node-positive Stage III NSCLC, and lung cancer utility studies. The meta-analysis was organized by treatment strategies, which included: neoadjuvant chemoradiation + surgery (NCR + S), neoadjuvant chemotherapy + surgery (NC + S), surgery + chemotherapy (S+ C), surgery + chemoradiation (S + CR). A Markov cohort model was constructed to estimate survival benefits and quality-adjusted life expectancy for each strategy.

RESULTS: Five clinical trials comprised the meta-analysis. S + C is the strategy with the greatest survival benefit (S + C > NCR +S > NC + S > S + CR), with an additional 6.4 ± 1.4 months more life expectancy than NCR +S. S + C is also estimated to lead to the greatest quality-adjusted life expectancy, with an additional 5.2 ± 1.1 months more quality-adjusted life expectancy than NCR + S. The strategy with the lowest survival benefit and the worst quality-adjusted life expectancy is S + CR, with 1.4 ± 1.1 fewer months of survival benefit and 1.9 ± 0.7 months lower quality-adjusted life expectancy than NC + S (10.8 ± 1.7 months and 8.5 ± 1.1 quality-adjusted months less than S + C).

CONCLUSIONS: Surgery followed by chemotherapy for node-positive Stage III NSCLC is estimated to maximize survival, and it is projected to have the greatest health benefits in terms of quality-adjusted life expectancy.