Lack of Adherence to Guideline-Based Imaging Before Subsequent Radiation in Patients with Non–Small Cell Lung Cancer: Impact on Patient Outcomes

Emily Sterbis; Rifei Liang; Premal Trivedi; Jennifer Kwak; Erica Cohen Major; Sana D. Karam; Rustain L. Morgan

doi:10.2967/jnumed.122.264131

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FIGURE 1.
Impact of imaging modality (CT/CTA alone vs. any PET) on 3-y overall (left) and cancer-specific (right) survival in patients with NSCLC, according to SEER, 2007–1015.

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TABLE 1.

Characteristics by Imaging Modality Before Subsequent RT of NSCLC Patients

Characteristic	Total	CT/CTA alone	Any PET	P
All patients	5,017	2,188	2,829
Race/ethnicity category
White NH	4,223 (84.2)	1,786 (81.6)	2,437 (86.1)	<0.0001^*
Black NH	337 (6.7)	183 (8.4)	154 (5.4)
Hispanic	179 (3.6)	80 (3.7)	99 (3.5)
Other/unknown	278 (5.5)	139 (6.4)	139 (4.9)
Patient region at diagnosis
East	1,061 (21.1)	493 (22.5)	568 (20.1)	0.0215^*
Midwest	617 (12.3)	285 (13.0)	332 (11.7)
South	1,510 (30.1)	618 (28.2)	892 (31.5)
West	1,829 (36.5)	792 (36.2)	1,037 (36.7)
Facility type
National Cancer Institute center	605 (12.1)	296 (13.5)	309 (10.9)	0.0179^*
Teaching hospital	2,021 (40.3)	873 (39.9)	1,148 (40.6)
Other/no hospital	2,391 (47.7)	1,019 (46.6)	1,372 (48.5)
Derived AJCC stage group, sixth edition
Stage I	1,597 (31.8)	518 (23.7)	1,079 (38.1)	<0.0001^*
Stage II	472 (9.4)	160 (7.3)	312 (11.0)
Stage III	1,511 (30.1)	675 (30.9)	836 (29.6)
Stage IVA	1,437 (28.6)	835 (38.2)	602 (21.3)
Initial treatment
RT	943 (18.8)	385 (17.6)	558 (19.7)	<0.0001^*
Surgery	1,217 (24.3)	421 (19.2)	796 (28.1)
Chemotherapy	659 (13.1)	402 (18.4)	257 (9.1)
Surgery and RT	112 (2.2)	39 (1.8)	73 (2.6)
Chemotherapy and RT	1,348 (26.9)	676 (30.9)	672 (23.8)
Chemotherapy and surgery	488 (9.7)	158 (7.2)	330 (11.7)
Chemotherapy, surgery, and RT	250 (5.0)	107 (4.9)	143 (5.1)
Diagnostic imaging category
CT/CTA alone	531 (10.6)	285 (13.0)	246 (8.7)	<0.0001^*
Any PET	4,440 (88.5)	1,885 (86.2)	2,555 (90.3)
No related imaging	46 (0.9)	18 (0.8)	28 (1.0)
Histologic subtype of NSCLC
Adenocarcinoma	2,546 (50.7)	1,157 (52.9)	1,389 (49.1)	<0.0001^*
Adenosquamous	120 (2.4)	47 (2.1)	73 (2.6)
Large cell carcinoma	117 (2.3)	54 (2.5)	63 (2.2)
Neuroendocrine	89 (1.8)	57 (2.6)	32 (1.1)
Squamous cell carcinoma	1,542 (30.7)	601 (27.5)	941 (33.3)
Other/not specified	603 (12.0)	272 (12.4)	331 (11.7)

↵* Statistically significant (P < 0.05).
NH = non-Hispanic; AJCC = American Joint Committee on Cancer.
Data are n followed by percentage in parentheses.

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TABLE 2.

Logistic Regression Predicting Whether Patients Received PET

Characteristic	OR	P	Global P
Race/ethnicity category
White NH (ref)			0.0044^*
Black NH vs. White NH	0.688 (0.54–0.88)	0.0023^*
Hispanic vs. White NH	0.958 (0.70–1.32)	0.7944
Other/unknown vs. White NH	0.752 (0.58–0.98)	0.0336^*
Patient region at diagnosis
West (ref)			0.0374^*
East vs. west	0.799 (0.67–0.95)	0.0111^*
Midwest vs. west	0.856 (0.70–1.05)	0.1390
South vs. west	0.996 (0.85–1.17)	0.9655
Derived AJCC stage group, sixth edition
Stage I (ref)			<0.0001^*
Stage II vs. stage I	0.880 (0.70–1.11)	0.2769
Stage III vs. stage I	0.695 (0.58–0.83)	<0.0001^*
Stage IVA vs. stage I	0.455 (0.38–0.55)	<0.0001^*
Initial treatment
RT (ref)			<0.0001^*
Chemotherapy vs. RT	0.625 (0.50–0.78)	<0.0001^*
Chemotherapy and RT vs. RT	0.827 (0.69–1.00)	0.0464^*
Chemotherapy and surgery vs. RT	1.337 (1.04–1.72)	0.0223^*
Chemotherapy, surgery, and RT vs. RT	0.969 (0.72–1.31)	0.8356
Surgery vs. RT	1.093 (0.90–1.33)	0.3676
Surgery and RT vs. RT	1.259 (0.83–1.92)	0.2843
Diagnostic imaging category
Any PET (ref)			0.0002^*
CT/CTA alone vs. any PET	0.673 (0.56–0.81)	<0.0001^*
No related imaging vs. any PET	1.178 (0.64–2.18)	0.6019
Histologic subtype of NSCLC
Adenocarcinoma (ref)			0.0183^*
Adenosquamous vs. adenocarcinoma	1.065 (0.72–1.57)	0.7528
Large cell carcinoma vs. adenocarcinoma	0.920 (0.62–1.35)	0.6718
Neuroendocrine vs. adenocarcinoma	0.576 (0.36–0.91)	0.0187^*
Squamous cell carcinoma vs. adenocarcinoma	1.176 (1.02–1.35)	0.0212^*
Other/not specified vs. adenocarcinoma	1.148 (0.95–1.39)	0.1537

↵* Statistically significant (P < 0.05).
NH = non-Hispanic; AJCC = American Joint Committee on Cancer.
Data in parentheses are 95% CIs.

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TABLE 3.

Multivariate Analysis of Survival at 3-Year Follow-Up

	Overall survival			Cancer-specific survival
Characteristic	Hazard ratio	P	Global P	Hazard ratio	P	Global P
Age category (y)
66–69 (ref)			0.0066^*			0.0079^*
70–74	0.988 (0.90–1.08)	0.7992		0.940 (0.85–1.04)	0.2436
≥75	1.115 (1.02–1.22)	0.0157^*		1.089 (0.99–1.20)	0.0901
Sex
Male (ref)			0.0012^*			0.0008^*
Female	0.886 (0.82–0.95)	0.0012^*		0.869 (0.80–0.94)	0.0008^*
Facility type
National Cancer Institute center (ref)			0.0174^*			0.0191^*
Other/no hospital	1.151 (1.02–1.30)	0.0205^*		1.164 (1.02–1.33)	0.0280^*
Teaching hospital	1.050 (0.93–1.18)	0.4213		1.047 (0.91– 0.20)	0.5064
Derived AJCC stage group, sixth edition
Stage I (ref)			<0.0001^*			<0.0001^*
Stage II	1.906 (1.62–2.25)	<0.0001^*		1.920 (1.59–2.31)	<0.0001^*
Stage III	2.057 (1.67–2.54)	<0.0001^*		2.135 (1.70–2.69)	<0.0001^*
Stage IVA	2.810 (2.11–3.74)	<0.0001^*		2.846 (2.08–3.89)	<0.0001^*
Initial treatment
Radiation (ref)			<0.0001^*			<0.0001^*
Chemotherapy	0.681 (0.58–0.80)	<0.0001^*		0.696 (0.58–0.83)	<0.0001^*
Chemotherapy and RT	0.533 (0.42–0.67)	<0.0001^*		0.537 (0.42–0.69)	<0.0001^*
Chemotherapy and surgery	0.278 (0.20–0.38)	<0.0001^*		0.272 (0.19–0.38)	<0.0001^*
Chemotherapy, surgery, and RT	0.337 (0.23–0.49)	<0.0001^*		0.330 (0.22–0.50)	<0.0001^*
Surgery	0.673 (0.59–0.76)	<0.0001^*		0.675 (0.58–0.78)	<0.0001^*
Surgery and RT	0.466 (0.34–0.63)	<0.0001^*		0.415 (0.29–0.59)	<0.0001^*
Histologic subtype of NSCLC
Adenocarcinoma (ref)			<0.0001^*			0.0005^*
Adenosquamous	1.471 (1.17–1.85)	0.0010^*		1.392 (1.07–1.81)	0.0138^*
Large cell carcinoma	1.416 (1.11–1.81)	0.0059^*		1.315 (1.00–1.72)	0.0470^*
Neuroendocrine	1.375 (1.02–1.85)	0.0342^*		1.455 (1.05–2.01)	0.0232^*
Squamous cell carcinoma	1.719 (1.40–2.11)	<0.0001^*		1.644 (1.32–2.05)	<0.0001^*
Other/not specified	1.728 (1.34–2.23)	<0.0001^*		1.687 (1.28–2.22)	0.0002^*
Diagnostic imaging category
Any PET (ref)			<0.0001^*			0.0001^*
CT/CTA alone	2.089 (1.55–2.81)	<0.0001^*		1.986 (1.45–2.73)	<0.0001^*
No related imaging	0.438 (0.27–0.72)	0.0011^*		0.448 (0.26–0.77)	0.0039^*
Imaging category before subsequent RT
Any PET (ref)			<0.0001^*			<0.0001^*
CT/CTA alone	1.417 (1.32–1.52)	<0.0001^*		1.430 (1.32–1.55)	<0.0001^*