PURPOSE To compare outcomes between lung stereotactic radiotherapy (SBRT) and wedge resection for stage I non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS One hundred twenty-four patients with T1-2N0 NSCLC underwent wedge resection (n = 69) or image-guided lung SBRT (n = 58) from February 2003 through August 2008. All were ineligible for anatomic lobectomy; of those receiving SBRT, 95% were medically inoperable, with 5% refusing surgery. Mean forced expiratory volume in 1 second and diffusing capacity of lung for carbon monoxide were 1.39 L and 12.0 mL/min/mmHg for wedge versus 1.31 L and 10.14 mL/min/mmHg for SBRT (P = not significant). Mean Charlson comorbidity index and median age were 3 and 74 years for wedge versus 4 and 78 years for SBRT (P < .01, P = .04). SBRT was volumetrically prescribed as 48 (T1) or 60 (T2) Gy in four to five fractions. Results Median potential follow-up is 2.5 years. At 30 months, no significant differences were identified in regional recurrence (RR), locoregional recurrence (LRR), distant metastasis (DM), or freedom from any failure (FFF) between the two groups (P > .16). SBRT reduced the risk of local recurrence (LR), 4% versus 20% for wedge (P = .07). Overall survival (OS) was higher with wedge but cause-specific survival (CSS) was identical. Results excluding synchronous primaries, nonbiopsied tumors, or pathologic T4 disease (wedge satellite lesion) showed reduced LR (5% v 24%, P = .05), RR (0% v 18%, P = .07), and LRR (5% v 29%, P = .03) with SBRT. There were no differences in DM, FFF, or CSS, but OS was higher with wedge. CONCLUSION Both lung SBRT and wedge resection are reasonable treatment options for stage I NSCLC patients ineligible for anatomic lobectomy. SBRT reduced LR, RR, and LRR. In this nonrandomized population of patients selected for surgery versus SBRT (medically inoperable) at physician discretion, OS was higher in surgical patients. SBRT and surgery, however, had identical CSS.

ContributorsGIW wrote and revised the manuscript in response to co-author comments. He finalized all the figures and tables, performed the literature search, and assisted with data interpretation. HJK critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. IBA performed the data analysis, constructed the figures and tables, and made important suggestions to improve the manuscript. H-CK assisted with the data analysis and also reviewed the manuscript. GRC critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. All other authors were given the opportunity to review the manuscript and make suggestions which GIW received, either revising the paper or providing explanations. All who are not deceased were involved with approval of the manuscript.

Background & Aims Following radiofrequency ablation (RFA), patients may experience recurrence of Barrett’s esophagus (BE) after complete eradication of intestinal metaplasia (CEIM). Rates and predictors of recurrence after successful eradication are poorly described. Methods We used the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA, to determine rates and factors that predicted recurrence of IM. We assessed recurrence by Kaplan-Meier analysis for the overall cohort and by worst pretreatment histology. Characteristics associated with recurrence were included in a logistic regression model to identify independent predictors. Results Among 5521 patients, 3728 had biopsies ≥12 months after initiation of RFA. Of these, 3169 (85%) achieved CEIM, and 1634 (30%) met inclusion criteria. Average follow-up was 2.4 years after CEIM. IM recurred in 334 (20%), and was non-dysplastic or indefinite for dysplasia in 86% (287/334); the average length of recurrent BE was 0.6 cm. In Kaplan-Meier analysis, more advanced pretreatment histology was associated with an increased yearly recurrence rate. Compared to patients without recurrence, patients with recurrence were more likely, based on bi-variate analysis, to be older, have longer BE segments, be non-Caucasian, have dysplastic BE before treatment, and require more treatment sessions. In multivariate analysis, likelihood for recurrence was associated with increasing age and BE length, and non-Caucasian race. Conclusion BE recurred in 20% of patients followed for an average of 2.4 years after CEIM. Most recurrences were short segments and were non-dysplastic or indefinite for dysplasia. Older age, non-Caucasian race, and increasing length of BE length were all risk factors. These risk factors should be considered when planning post-RFA surveillance intervals.

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Background & Aims Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, predictors of EAC, and EAC-specific and all-cause mortality rates. Methods We assessed outcomes in a multicenter study of RFA for BE. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (both all-cause and EAC-specific) rates were calculated, and adjusted all-cause mortality rates were assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality. Results Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years (PY)), and 9 (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in non-dysplastic BE (NDBE) was 0.5/1000 PY. Overall, 157 (3%) patients died during follow-up (all-cause mortality 11.2/1000 PY). On multivariate logistic regression, baseline BE length (OR 1.1 per cm) and baseline histology (ORs of 5.8 and 50.3 for low grade dysplasia and high grade dysplasia (HGD) respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extra-esophageal cancers (15%). No deaths were associated with RFA. Conclusion In this multicenter registry of RFA for BE, death from EAC was rare. The incidence of EAC was markedly lower than natural history studies, with the greatest absolute benefit seen in HGD.

Background: Low-dose computed tomography (LDCT) scan for lung cancer screening is underutilized.Studies suggest that up to one-third of providers do not know the current lung cancer screening guidelines.Thus, identifying the barriers to utilization of LDCT scan is essential. Methods: Primary care providers in three different healthcare settings in the United States were surveyed to assess provider knowledge of LDCT scan screening criteria, lung cancer screening practices, and barriers to the utilization of LDCT scan screening. Fisher's Exact, Chi-Squared, and Kruskal-Wallis tests were used to compare provider responses. Multivariable logistic regression was used to test the association between provider characteristics and the likelihood of utilizing LDCT scan for lung cancer screening. Results: The survey was sent to 614 providers, with a 15.7% response rate. Overall, 29.2% of providers report never ordering LDCT scans for eligible patients. Providers practicing at a community or academic hospital more frequently order LDCT scans than those practicing at a safety net hospital. Academic-and community-based providers received a significantly higher mean knowledge score than safety net-based providers [academic 6.84 (SD 1.33), community 6.72 (SD 1.46), safety net 5.85 (SD 1.38); P<0.01]. Overall, only 6.2% of respondents correctly identified all six Centers for Medicare and Medicaid Services eligibility criteria when challenged with three incorrect criteria. Common barriers to utilization of LDCT scan included failure of the electronic medical record (EMR) to notify providers of eligible patients (54.7%), patient refusal (37%), perceived high false-positive rate leading to unnecessary procedures (18.9%), provider time constraints (16.8%), and lack of insurance coverage (13.7%). Conclusions: Provider knowledge of lung cancer screening guidelines varies, perhaps contributing to underutilization of LDCT scan for lung cancer screening. Improved provider education at safety net hospitals and improving EMR-based best practice alerts may improve the rate of lung cancer screening.