Retrospective cohort study of association of early surgical resection with survival in patients with stage I non-small cell lung cancer

Timely surgical resection is the cornerstone of curative treatment for early-stage non-small cell lung cancer (NSCLC). The optimal interval between diagnosis and surgery is not clear. A retrospective cohort study using the National Cancer Database Particpant User File (2004-2023) evaluated the association between time to treatment (TTT) and long-term survival in patients with stage I NSCLC undergoing anatomic resection. Patients receiving neoadjuvant or adjuvant therapy with stage II to IV disease, TTT greater than 120 days, or missing survival data were excluded. Propensity score matching balanced demographic, clinical, socioeconomic, and facility-level characteristics. Among 157 894 patients, the median age was 69 years (IQR 62-75); 55.9% were female, The median TTT increased from 23 (IQR 0-44) days in 2004 to 43 (23-66) days in 2022 (p<0.001), while same-day diagnosis and resection declined for 30.6% to 16.7% (p<0.001). Overall, 71 477 patients (45.3%) underwent surgery within 4 weeks of diagnosis, and 86 417 (54.7%) after 4 weeks. After propensity score matching, balanced groups of 56 386 patients were compared. Patients undergoing surgery within 4 weeks had significantly improved 5-year overall survival compared with those treated after 4 weeks (74.1% versus 69.6%; p<0.001). Delays beyond 4 weeks were associated with non-Hispanic Black race, Medicaid insurance or uninsured status, and care across multiple facilities. The authors conclude that in this national cohort of patients undergoing anatomic resection for stage I NSCLC, time to surgical resection increased substantially between 2004 and 2022. Mortality was lowest with surgery 2 to 4 weeks after diagnosis and increased substantially beyond 8 weeks (visual abstract).