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We thank Dr Gard and Dr Voskoboynik for their interest in our article1Navani N. Fisher D.J. Tierney J.F. et al.NSCLC Meta-analysis Collaborative Group. The accuracy of clinical staging of stage I-IIIa non-small cell lung cancer: an analysis based on individual participant data.Chest. 2019; 155: 502-509Abstract Full Text Full Text PDF Scopus (29) Google Scholar and for their thoughtful comments. We agree that timeliness of care appears to be important for patients undergoing lung cancer diagnosis and treatment and is the subject of an ongoing systematic review.2Hall H. Navani N. Association between time to treatment and survival in non-small cell lung cancer: a systematic review. PROSPERO 2018 CRD42018099239.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=99239Date accessed: May 8, 2019Google Scholar A previous randomized trial of endobronchial ultrasound by our group3Navani N. Nankivell M. Lawrence D.R. et al.Lung cancer diagnosis and staging with endobronchial ultrasound-guided transbronchial needle aspiration compared with conventional approaches: an open-label, pragmatic, randomised controlled trial.Lancet Respir Med. 2015; 3: 282-289Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar resulted in faster diagnosis and was also associated with improved survival. Reduced time to treatment may also improve patient experience and result in fewer patients reporting a drop in performance status. This has prompted health-care policy makers in England to stipulate a reduction in the maximum time from presentation to treatment from 62 to 49 days.4Peake M.D. Navani N. Baldwin D.R. The continuum of screening and early detection, awareness and faster diagnosis of lung cancer.Thorax. 2018; 73: 1097-1098Google Scholar However, timeliness of care may also be associated with other patient and system factors that may also confound outcomes. For example, patients with comorbidities may have slower pathways to treatment, while hospitals with expertise in lung cancer care may have prioritized access to diagnostics such as PET-CT imaging for patients with lung cancer but also may carry out more invasive and accurate staging. In the important study by Yang and colleagues,5Yang C.J. Wang H. Kumar A. et al.Impact of timing of lobectomy on survival for clinical stage IA lung squamous cell carcinoma.Chest. 2017; 152: 1239-1250Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar stage shift between clinical and pathologic diagnosis was not reported and therefore it is not possible to be definitive that stage migration occurred while awaiting for surgery. The study also excluded patients with adenocarcinomas, which may have slower volume-doubling time, although occult N2 disease is more likely in patients with this histology.6Bille A. Woo K.M. Ahmad U. Rizk N.P. Jones D.R. Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung cancer patients.Eur J Cardiothorac Surg. 2017; 51: 674-679Crossref PubMed Scopus (63) Google Scholar In our study, individual patient data were obtained from patients in the control arms of randomized trials of neoadjuvant chemotherapy. Timing of surgery in these trial protocols or reports is shown in Table 1. Time to surgery was available for 86% of patients and varied from immediate to 4 weeks. In the study by Yang and colleagues, patients whose surgery was 38 or more days after diagnosis were found to have worse survival, and therefore it is less likely that timing of surgery significantly influenced our results.Table 1Time to Surgery in Control Arm of Randomized Trials of Neo-adjuvant ChemotherapyTrialaFor full references, see Navani et al.1No. of Patients in Control ArmNo. of Patients Providing Clinical Pathologic Staging DataControl Arm Surgery DetailsM.D. Anderson (USA); Roth et al/19943232“Immediate surgical resection”MIP-91 (France); Depierre et al/2002176170Surgery “during first week” following randomizationNetherlands; Splinter et al/20004037Surgery within 2 wk of randomizationJCOG 9209 (Japan); Nagai et al/20033131Not reportedFinland; Mattson et al/20033223Not reportedMRC LU22 (UK); Gilligan et al/2007261194Surgery within 4 wk of randomizationSWOG S9900 (USA); Pisters et al/2010174170“Patients will be registered and proceed to surgery within 14 days of registration”China; Wu et al/20022320Not reported (abstract)China; Yang et al/20052121Not reported (abstract)a For full references, see Navani et al.1Navani N. Fisher D.J. Tierney J.F. et al.NSCLC Meta-analysis Collaborative Group. The accuracy of clinical staging of stage I-IIIa non-small cell lung cancer: an analysis based on individual participant data.Chest. 2019; 155: 502-509Abstract Full Text Full Text PDF Scopus (29) Google Scholar Open table in a new tab Our data underline the importance of ensuring accurate clinical staging for optimal patient outcomes. We agree that time to treatment is an important metric for clinical care and should be emphasized, but not at the expense of accurate guideline-based clinical staging. The Accuracy of Clinical Staging of Stage I-IIIa Non-Small Cell Lung Cancer: An Analysis Based on Individual Participant DataCHESTVol. 155Issue 3PreviewClinical staging of non-small cell lung cancer (NSCLC) helps determine the prognosis and treatment of patients; few data exist on the accuracy of clinical staging and the impact on treatment and survival of patients. We assessed whether participant or trial characteristics were associated with clinical staging accuracy as well as impact on survival. Full-Text PDF Open AccessSetting the Stage: Delay to Surgery May Upstage Patients With Non-Small Cell Lung CancerCHESTVol. 156Issue 3PreviewIn a previous issue of CHEST (March 2019), Navani and colleagues1 presented results of a meta-analysis focused on the accuracy of clinical staging of non-small cell lung cancer (NSCLC) in clinical trial patients. In their analysis, clinical staging was accurate in just 52% of cases, with 34% of patients clinically understaged based on the pathologic TNM stage. This effect was seen across all subgroups stratified by stage. However, the meta-analysis did not take into account the important potential confounder of elapsed time between clinical staging and pathologic staging, which may contribute to understaging and progression of disease. Full-Text PDF