Background: Prior studies have reported a female survival advantage in non-small cell lung cancer (NSCLC), but estimates have relied on Kaplan-Meier and Cox regression methods that may bias disease-specific survival when competing causes of death are common. We applied competing risk analysis to quantify the independent association between sex and lung cancer-specific survival (LCSS) in NSCLC.Methods: We analyzed data from the National Cancer Institute-sponsored Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which enrolled ~155,000 adults aged 55-74 years across 10 U.S. centers from 1993 to 2001. Participants with histologically confirmed primary NSCLC who completed at least one baseline or follow-up questionnaire were included. Sociodemographics, smoking history, and comorbidities were self-reported; tumor characteristics and treatment were obtained from registry and pathology records. The cause of death was ascertained from family/provider reports and National Death Index Plus linkage. Unadjusted and multivariable Fine-Gray subdistribution hazard models evaluated the association between sex and LCSS, adjusting for age, race/ethnicity, marital status, smoking (status and pack-years), comorbidities, tumor stage, histology, location, and stage-appropriate treatment. Missing data were handled via multiple imputation.Results: The final cohort included 2,793 NSCLC patients (41% female; mean age 64.4 years). Over a median follow-up of 9.2 years, 2,006 (72%) patients died of lung cancer and 531 (19%) died of other causes. In unadjusted analysis, female sex was associated with improved LCSS (HR 0.81, 95% CI 0.74-0.88). After adjustment for confounders and competing risks, female sex remained independently associated with improved LCSS (adjusted subdistribution HR 0.85, 95% CI 0.74-0.98). The female survival advantage was consistent across all prespecified subgroups (all interaction p>0.05).Conclusion: In this prospectively followed cohort with competing-risk-adjusted analysis, female sex was independently associated with an ~15% reduction in lung cancer-specific mortality in NSCLC. Sex should be considered as a prognostic factor in NSCLC risk stratification models, treatment, and trial design.

Abstract Purpose: Lung cancer causes more than 130,000 deaths each year in the United States. Although females with non-small cell lung cancer (NSCLC) appear to have better survival than males, many prior studies did not fully account for key confounders, including smoking history and competing causes of mortality. Moreover, large cohort analyses often relied on Cox models, which may overestimate cause-specific risks when competing mortality is substantial. Hence, in this study, we assessed whether sex-based survival differences in NSCLC persist after adjusting for these confounders and applied competing risk regression to adequately account for competing causes of death and more accurately quantify lung cancer-specific mortality. Methods: Using data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial, we selected patients whose first-ever malignancy was primary NSCLC, excluding anyone with a prior other cancer diagnosis or secondary/metastatic lung tumors. Lung cancer-specific survival for females versus males was evaluated using Fine and Gray competing risk models, adjusting for sociodemographic factors, cancer location, histology, treatment, smoking status, and comorbidities. Because patients with NSCLC experience substantial mortality from non-cancer-related causes, we applied a competing risk model to accurately account for this. This approach avoids the more than twofold (2.25-fold) overestimation of cause-specific risk that can occur when Cox models are used in elderly populations. All analyses were performed using SAS 9.4. Results: Among 2,793 patients (59% male, 41% female), 2,006 (72%) experienced lung cancer-related death, 531 (19%) died from other causes, and 256 (9%) were alive at last follow-up. Female patients were more likely to be never smokers (14% vs 5%, p<0.0001), have adenocarcinoma (55% vs 42%, p<0.0001), and less likely to have cardiovascular disease (heart failure: 7% vs 18%, p<0.0001). Unadjusted Fine and Gray models showed (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.74-0.88) lower lung cancer-specific mortality among women. Adjusted analyses demonstrated that female sex (HR: 0.85, 95% CI: 0.74-0.98) was associated with decreased risk of lung cancer-specific death. A significant interaction between female sex and stage IV disease (b coefficient: 0.18, 95% CI: 0.99-1.45) showed that lung cancer-specific survival of women and men was similar among patients with advanced disease. Conclusions: Females with NSCLC demonstrate reduced lung cancer-specific mortality after adjustment for competing risks and confounders. These results could be suggestive of sex-based disparities in inherent biological differences in tumor biology, natural disease progression, or overall increased life expectancy in females, further supporting investigating molecular pathways including hormonal signaling and immune responses to guide optimal treatment strategies. Citation Format: Veer N. Shah, Grace Mhango, Darshi Shah, Paolo Boffetta, Juan P. Wisnivesky. Sex-based differences in lung cancer survival: A competing risks model using the PLCO trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2026; Part 1 (Regular Abstracts); 2026 Apr 17-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2026;86(7 Suppl):Abstract nr 906.

Epidemiological studies have shown mixed results as to whether women are more susceptible to lung cancer than men. We studied 154,897 never-smokers and ever-smokers in the Prostate-Lung-Colon-Ovary (PLCO) trial and 53,452 heavy ≥30 pack-year smokers in National-Lung-Screening-Trial (NLST), 55-74 years of age. We calculated female to male lung cancer incidence rate ratios (IRR) using Poisson regression to adjust for established risk factors. In PLCO, women were more likely than men to be never smokers (56.2 % vs. 31.7 %, p < 0.01). Among ever smokers, women had fewer pack years than men (23 vs. 33 in PLCO, and 45 vs. 52 in NLST, p < 0.01). In adjusted analyses of PLCO, women had similar rates of lung cancer to men in the never-smoker group (IRR: 1.23, 95 %-confidence interval: 0.90-1.67), and the 1-15 (0.82, 0.59-1.14), 15-30 (0.95, 0.78-1.15), 30-45 (0.95, 0.80-1.11), 45-60 (0.94, 0.80-1.11), 60-75 (0.99, 0.81-1.19) and 75-100 (0.84, 0.67-1.06) pack-year groups. Lung cancer risk was lower among women in the 100+ pack year group (0.66, 0.48-0.90). In NLST, women were equally susceptible to lung cancer as men in all pack-year groups. There was no significant sex-race interaction (p > 0.05) in either trial, while there was a sex-age interaction (p = 0.02) in NLST. Our analysis of two large randomized cancer-screening trials with predominantly white participants shows that for never-smokers or ever-smokers aged >55 years, women are at similar risk of lung cancer compared to men. Consequently, lung cancer screening efforts, policies and campaigns, when addressing individuals of these demographics, should be equally focused on men and women.

Background: Radiation therapy (RT) is standard of care adjuvant therapy after lumpectomy for early breast cancer (including DCIS). However, lung exposure to RT delivered for breast cancer therapy has been shown to increase risk for lung cancer. In recent years, breast RT has evolved to include newer techniques such as prone positioning and hypofractionationed schedules, which use larger doses in an abbreviated period of time and impart less exposure to radiation when compared to conventional radiotherapy. The American Society for Radiation Oncology has released guidelines recommending hypofractionated therapy for breast cancer treatment. However, it remains unclear if modern breast RT techniques may reduce risk of developing subsequent lung cancer. Methods: Patients with clinical stage I-IIIC breast cancer who were treated with breast RT between 2000 and 2020 were identified in the Surveillance, Epidemiology and End Results (SEER) database. A competing risk model was used to estimate if breast RT was associated with increased risk of ipsilateral but not contralateral lung cancer. Results: We identified 853,178 patients with breast cancer in SEER, of whom 468,113 underwent RT. Of the patients who underwent RT, 2,203 developed ipsilateral lung cancer (incidence rate: 5.8 cases per 10,000 person-years (PYs); 95% CI: 5.5 cases per 10,000 PYs to 6.0 cases per 10,000 PYs ) and 2,221 developed contralateral lung cancer (incidence rate: 5.8 cases per 10,000 person years; 95% CI: 5.6 cases per 10,000 PYs to 6.1 cases per 10,000 PYs). Of the 385,065 patients in our cohort who did not undergo RT, 1,906 developed ipsilateral lung cancer (incidence rate: 6.4 cases per 10,000 person years; 95% CI: 6.1 cases per 10,000 PYs to 6.7 cases per 10,000 PYs) and 1,875 developed contralateral lung cancer (incidence rate: 6.3 cases per 10,000 person years; 95% CI: 6.0 cases per 10,000 PYs to 6.6 cases per 10,000 PYs). Adjusted analyses showed that the hazard ratio for ipsilateral cancer among patients treated with RT was 0.93 (CI 0.88-0.99) and was not elevated as seen previously. Conclusions: While older forms of radiation therapy were associated with increased risk of subsequent lung cancer, newer techniques such as prone positioning and hypofractionated schedules no longer appear to portend the same risk for those with stage I-IIIC breast cancer. These findings further support establishing new techniques as standard of care.

•Disparities persist in surgical management of early-stage lung cancer.•Candidacy for sub-lobar resection did not vary by patient race/ethnicity.•Nor did race/ethnicity influence provider recommendation for sub-lobar resection.

BackgroundThis brief report examines statin prescription trends for primary cardiovascular disease (CVD) prevention in breast cancer (BC) survivors with diabetes, a large population at particularly high CVD risk.MethodsA population-based, retrospective cohort study was conducted using Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked to Medicare claims. We identified women with preexisting diabetes who were diagnosed with stage 0–III primary BC between 2008 and 2017 without preexisting CVD. We assessed statin prescription rates over time and also examined differences in statin prescription rates according to patient sociodemographic characteristics. Using a multivariate logistic regression adjusted for sociodemographic and clinical variables, independent predictors of statin prescription were identified.ResultsOf 8,423 BC patients with diabetes without preexisting CVD, 5,698 (68%) had a statin prescription. Statin prescriptions increased over time (BC diagnosis year 2008–2009: 65%, 2010–2011: 67%, 2012–2013: 66%, 2014–2015: 69%, 2016–2017: 70%; p = 0.01) and differed by age (66–69: 66%, 70–74: 70%, 75–79: 69%, ≥80: 65%; p < 0.01) and race (White: 68%, Black: 62%, Latina: 66%, Other: 72%; p < 0.01). In a multivariate analysis, race (Black vs. White: OR 0.80, 95% CI: 0.68–0.95) remained a predictor of statin prescription.ConclusionIn older early-stage BC survivors, statin prescriptions increased over time and varied by age, race, and BC stage. These findings can potentially inform strategies to improve guideline-concordant statin prescriptions in a group at high risk for CVD and reduce disparities.

Background:Diabetes is a common comorbidity in patients with early-stage non-small cell lung cancer (NSCLC), a growing population due to increased LC screening. However, it is unknown if diabetes is associated with less aggressive NSCLC treatment and worse NSCLC outcomes. This study aimed to investigate treatment patterns and outcomes of older patients with Stage I NSCLC and diabetes. Methods:Using national cancer registry data linked to Medicare, we identified patients ≥65 years old with Stage I NSCLC. Patients were categorized as having no diabetes, diabetes without severe complications (DM-c), or diabetes with ≥1 severe complication (DM + c). We used multinomial logistic regression to assess the association of diabetes and NSCLC treatment. The association of diabetes category with NSCLC and non-NSCLC survival was analyzed with Fine-Grey competing-risks regression. Results:In 25,358 patients (75% no diabetes, 12% DM-c and 13% had DM + c), adjusted analyses showed that DM-c and DM + c were associated with increased odds of receiving limited resection rather than lobectomy (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.07-1.37 and OR 1.42, 95% CI 1.26-1.59, respectively). Competing risk regression showed diabetes was associated with increased risk of non-NSCLC death (DM-c hazard ratio [HR] 1.16, 95% CI: 1.08-1.25, DM + c HR 1.49, 95% CI: 1.40-1.59), but not NSCLC-specific death. Conclusion:This study uncovers critical information on how diabetes is associated with less aggressive early-stage NSCLC care in older patients. This study also confirms that diabetes increases death from non-lung cancer causes and managing comorbidities is crucial to improving outcomes in older early-stage NSCLC survivors.

BACKGROUND:To describe outcomes and compare the effectiveness of stereotactic body radiotherapy (SBRT) versus 3-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) in patients with stage IIA lymph node-negative (N0) non-small cell lung cancer (NSCLC) tumors > 5 cm. METHODS:We used the SEER-Medicare database (2005-2015) to identify patients > 65 years with stage IIA (AJCC TNM7) N0 NSCLC > 5 cm tumors who were treated with SBRT, IMRT, and 3DCRT. We used propensity score methods with inverse probability weighting to compare lung cancer-specific survival (LCSS), overall survival (OS), and toxicity. RESULTS:Of 584 patients, 88 (15%), 140 (24%), and 356 (61%) underwent SBRT, IMRT, and 3DCRT, respectively. The SBRT group was older (P = .004), had more comorbidities (P = .02), smaller tumors (P = .03), and more adenocarcinomas (P < .0001). We found a trend towards higher median unadjusted OS with SBRT compared to IMRT and 3DCRT (19 vs. 13 and 14 months, respectively, P = .37). In our propensity score-adjusted analyses, SBRT was significantly associated with better OS and LCSS compared to IMRT (HROS: 0.78, 95% CI: 0.68-0.89, HRLCSS: 0.70, 95% CI: 0.60-0.81) and 3DCRT (HROS: 0.81, 95% CI: 0.72-0.93, HRLCSS: 0.80, 95% CI: 0.68-0.93). SBRT-treated patients also had lower overall adjusted complication rates compared to IMRT (OR: 0.74, 95% CI: 0.55-0.99) and 3DCRT (OR: 0.53, 95% CI: 0.40-0.71). CONCLUSION:For patients with NSCLC tumors > 5 cm, SBRT trends towards fewer toxicities and improved survival compared to other forms of radiotherapy. Our findings support SBRT as an appropriate treatment strategy for older patients with larger inoperable NSCLC tumors.

Background Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however. Methods We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases. Results Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts. Conclusions Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.

Introduction: Non-small cell lung cancer (NSCLC) patients frequently have major comorbidities but there is scarce data regarding the impact of these conditions on management strategies. We used simulation modeling to compare different treatments for stage I NSCLC for patients with common major comorbidities. Methods: We used data on NSCLC patinet outcomes and quality of life from: (1) the Surveillance Epidemiology and End Results (SEER) database linked to Medicare claims; (2) Kaiser Permanente Southern California electronic health records; and (3) SEER-Medical Health Outcomes Survey to parameterize a novel simulation model of management and outcomes for stage I NSCLC. Relative efficacy of treatment modalities (lobectomy, segmentectomy, wedge resection and stereotactic body radiotherapy [SBRT]) was collected from existing literature and combined using evidence synthesis methods. We then simulated multiple randomized trials comparing these treatments in a variety of scenarios, estimating quality adjusted life expectancy (QALE) according to age, tumor size, histologic subtype, and comorbidity status. Results: Lobectomy and segmentectomy yielded the greatest QALE gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex and age; wedge resection was among the optimal strategies for women aged 80-84 with tumors 0-2 cm in size. SBRT was included in some optimal strategies for patients aged 80-84 with multimorbidity. Conclusions: In simulated comparative trials of four common treatments for stage I NSCLC, aggressive surgical management was typically associated with the greatest projected QALE gains despite the presence of comorbidities, although less aggressive strategies were predicted to be non-inferior in some older comorbid patient groups.

Introduction: Advances in breast cancer (BC) diagnosis and treatment have increased the number of long-term survivors. Consequently, survivors of primary BC are at a greater risk of developing second primary cancers (SPCs). The risk factors for SPCs among BC survivors including sociodemographic, cancer treatment, comorbidities, and other medications have not been comprehensively examined. The purpose of this study is to assess the incidence and clinicopathologic factors associated with risk of SPCs. Methods: We analyzed 170, 639 women with early-stage primary BC diagnosed between January 2000-December 2015 from the Medicare-linked Surveillance Epidemiology and End Results (SEER-Medicare) database. SPC was defined as any diagnosis of malignancy occurring within the study period and at least two months after primary BC diagnosis. Univariate analyses compared baseline characteristics between those who developed a SPC and those who did not. We evaluated the cause-specific hazard of developing a SPC in the presence of death as a competing risk.Results: Of the study cohort, 20,838 (12%) of BC survivors developed a SPC and BC was the most common SPC type (32%). The median time to SPC was 42 months. Women who were white, older, and with fewer comorbidities were more likely to develop a SPC. While statins [hazard ratio (HR) 1.060 (1.016 - 1.106)] and anti-hypertensives [HR 1.517 (1.461 – 1.575)] increased the hazard of developing a SPC, aromatase inhibitor therapy [HR 0.588 (0.542 – 0.638)] and bisphosphonates [HR 0.897 (0.848 – 0.949)] were associated with a decreased hazard of developing any SPC, including non-breast SPCs.Conclusion: Our study shows that specific clinical factors including type of cancer treatment, medications, and comorbidities are associated with increased risk for the development of SPCs among older BC survivors. These results can increase patient and clinician awareness, target cancer screening among BC survivors, as well as developing risk-adapted management strategies.

AbstractBackgroundGastroenteropancreatic neuroendocrine tumors (GEP‐NETs) are increasingly common malignancies and tend to have favorable long‐term prognoses. Somatostatin analogues (SSA) are a first‐line treatment for many NETs. Short‐term experiments suggest an association between SSAs and hyperglycemia. However, it is unknown whether there is a relationship between SSAs and clinically significant hyperglycemia causing development of diabetes mellitus (DM), a chronic condition with significant morbidity and mortality.AimIn this study, we aimed to compare risk of developing DM in patients treated with SSA vs no SSA treatment.Methods and ResultsUsing the Surveillance, Epidemiology, and End Results (SEER) database and linked Medicare claims (1991‐2016), we identified patients age 65+ with no prior DM diagnosis and a GEP‐NET in the stomach, small intestine, appendix, colon, rectum, or pancreas. We used χ2 tests to compare SSA‐treated and SSA‐untreated patients and multivariable Cox regression to assess risk factors for developing DM. Among 8464 GEP‐NET patients, 5235 patients had no prior DM and were included for analysis. Of these, 784 (15%) patients received SSAs. In multivariable analysis, the hazard ratio of developing DM with SSA treatment was 1.19, which was not statistically significant (95% CI 0.95‐1.49). Significant risk factors for DM included black race, Hispanic ethnicity, prior pancreatic surgery, prior chemotherapy, tumor size >2 cm, pancreas tumors, and higher Charlson scores.ConclusionDM was very common in GEP‐NET patients, affecting 53% of our cohort. Despite prior studies suggesting an association between SSAs and hyperglycemia, our analysis found similar risk of DM in SSA‐treated and SSA‐untreated GEP‐NET patients. Further studies are needed to better understand this relationship. As NET patients have increasingly prolonged survival, it is crucial to identify chronic conditions such as DM that these patients may be at elevated risk for.

Background Medical centers with varying levels of expertise treat gastroenteropancreatic neuroendocrine tumors (GEP-NETs), which are relatively rare tumors. This study assesses the impact of center volume on GEP-NET treatment outcomes. Methods We used the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims data. The data includes patients diagnosed between 1995 and 2010 who had no health maintenance organization (HMO) coverage, participated in Medicare parts A and B, were older than 65 at diagnosis, had tumor differentiation information, and had no secondary cancer. We identified medical centers at which patients received GEP-NET treatment (surgery, chemotherapy, somatostatin analogues, or radiation therapy) using Medicare claims data. Center volume was divided into 3 tiers – low, medium, and high – based on the number of unique GEP-NET patients treated by a medical center over 2 years. We used Kaplan-Meier curves and Cox regression to assess the association between volume and disease-specific survival. Results We identified 899 GEP-NET patients, of whom 37, 45, and 18% received treatment at low, medium volume, and high-volume centers, respectively. Median disease-specific survival for patients at low and medium tiers were 1.4 years and 5.3 years, respectively, but was not reached for patients at high volume centers. Results showed that patients treated at high volume centers had better survival than those treated in low volume centers (HR: 0.63, 95% CI: 0.4–0.9), but showed no difference in outcomes between medium and high-volume centers. Conclusions Our results suggest that for these increasingly common tumors, referral to a tertiary care center may be indicated. Physicians caring for GEP-NET patients should consider early referral to high volume centers.

Rationale: Chronic obstructive pulmonary disease (COPD) is a well-established independent risk factor for lung cancer; however, the literature on the association between asthma and lung cancer is mixed. Whether asthma-COPD overlap (ACO) is associated with lung cancer has not been studied. Objectives: We aimed to compare lung cancer risk among patients with ACO versus COPD and other conditions associated with airway obstruction. Methods: We studied 13,939 smokers from the National Lung Cancer Screening Trial who had baseline spirometry and used spirometric indices and history of childhood asthma to categorize participants into five specific airway disease subgroups. We used Poisson regression to compare unadjusted and adjusted lung cancer risk. Results: The incidence rate of lung cancer per 1,000 person-years was as follows: ACO, 13.2 (95% confidence interval [CI], 8.1-21.5); COPD, 11.7 (95% CI, 10.5-13.1); asthmatic smokers, 1.8 (95% CI, 0.6-5.4); Global Initiative for Chronic Obstructive Lung Disease-Unclassified, 7.7 (95% CI, 6.4-9.2); and normal spirometry smokers, 4.1 (95% CI, 3.5-4.8). Patients with ACO had increased adjusted risk of lung cancer compared with patients with asthma (incidence rate ratio [IRR], 4.5; 95% CI, 1.3-15.8) and normal spirometry smokers (IRR, 2.3; 95% CI, 1.3-4.2) in models adjusting for other risk factors. Adjusted lung cancer incidence in patients with ACO and COPD were not found to be different (IRR, 1.2; 95% CI, 0.7-2.1). Conclusions: The risk of lung cancer among patients with ACO is similar to those with COPD and higher than other groups of smokers. These results provide further evidence that COPD, with or without a history of childhood asthma, is an independent risk factor for lung cancer.

BACKGROUND:Racial disparities in resection of non-small cell lung cancer (NSCLC) are well documented. Patient-level and system-level factors only partially explain these findings. Although physician-related factors have been suggested as mediators, empirical evidence for their contribution is limited. OBJECTIVE:To determine if racial disparities in receipt of thoracic surgery persisted after patients had a surgical consultation and whether there was a physician contribution to disparities in care. METHODS:The authors identified 19,624 patients with stage I-II NSCLC above 65 years of age from the Surveillance-Epidemiology and End-Results-Medicare database. They studied black and white patients evaluated by a surgeon within 6 months of diagnosis. They assessed for racial differences in resection rates among surgeons using hierarchical linear modeling. Our main outcome was receipt of NSCLC resection. A random intercept was included to test for variability in resection rates across surgeons. Interaction between patient race and the random surgeon intercept was used to evaluate for heterogeneity between surgeons in resection rates for black versus white patients. RESULTS:After surgical consultation, black patients were less likely to undergo resection (adjusted odds ratio, 0.57; 95% confidence interval, 0.47-0.69). Resection rates varied significantly between surgeons (P<0.001). A significant interaction between the surgeon intercept and race (P<0.05) showed variability beyond chance across surgeons in resection rates of black versus white patients. When the model included thoracic surgery specifalization the physician contribution to disparities in care was decreased. CONCLUSIONS:Racial disparities in resection of NSCLC exist even among patients who had access to a surgeon. Heterogeneity between surgeons in resection rates between black and white patients suggests a physician's contribution to observed racial disparities. Specialization in thoracic surgery attenuated this contribution.

BACKGROUND Although asthma has been suggested as a risk factor for cardiovascular disease (CVD), robust longitudinal evidence of this relationship is limited. RESEARCH QUESTION Using Framingham Offspring Cohort data, we sought to longitudinally examine the association between asthma and lifetime risk of CVD while controlling for cardiovascular risk factors included in the Framingham Risk Score. STUDY DESIGN AND METHODS We analyzed data from a prospective population-based cohort of 3,612 individuals, ages 17 to 77 years, who participated in Framingham Offspring Study examinations from 1979 to 2014. Asthma was defined based on physician diagnosis during study interviews. Incident CVD included myocardial infarction (MI), angina, coronary insufficiency, stroke, transient ischemic attack, or heart failure. Time-dependent Cox regression models were used to evaluate the relationship between asthma and CVD incidence. RESULTS Overall, 533 (15%) participants had a diagnosis of asthma and 897 (25%) developed CVD during the course of the study. Unadjusted analyses revealed that asthma was associated with increased CVD incidence (hazard ratio [HR]: 1.40; 95% confidence interval [CI]: 1.17-1.68). Cox regression also showed an adjusted association between asthma and CVD incidence (HR: 1.28, 95% CI: 1.07-1.54) after controlling for established cardiovascular risk factors. INTERPRETATION Our prospective analysis with >35 years of follow-up shows that asthma is a risk factor for CVD after adjusting for potential confounders. When assessing risk of cardiovascular disease, asthma should be evaluated and managed as a contributing risk factor to morbidity and mortality.

Purpose Lung cancer risk models optimise screening by identifying subjects at highest risk, but none of them consider emphysema, a risk factor identifiable on baseline screen. Subjects with a negative baseline low-dose CT (LDCT) screen are at lower risk for subsequent diagnosis and may benefit from risk stratification prior to additional screening, thus we investigated the role of radiographic emphysema as an additional predictor of lung cancer diagnosis in participants with negative baseline LDCT screens of the National Lung Screening Trial. Methods Our cohorts consist of participants with a negative baseline (T0) LDCT screen (n=16 624) and participants who subsequently had a negative 1-year follow-up (T1) screen (n=14 530). Lung cancer risk scores were calculated using the Bach, PLCOm2012 and Liverpool Lung Project models. Risk of incident lung cancer diagnosis at the end of the study and number screened per incident lung cancer were compared between participants with and without radiographic emphysema. Results Radiographic emphysema was independently associated with nearly double the hazard of lung cancer diagnosis at both the second (T1) and third (T2) annual LDCT in all three risk models (HR range 1.9–2.0, p<0.001 for all comparisons). The number screened per incident lung cancer was considerably lower in participants with radiographic emphysema (62 vs 28 at T1 and 91 vs 40 at T2). Conclusion Radiographic emphysema is an independent predictor of lung cancer diagnosis and may help guide decisions surrounding further screening for eligible patients.

BACKGROUND:Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited. METHODS:Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs. RESULTS:In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02). CONCLUSIONS:RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

BACKGROUND:Some interstitial lung diseases are associated with lung cancer. However, it is unclear whether asymptomatic interstitial lung abnormalities convey an independent risk. OBJECTIVES:The goal of this study was to assess whether interstitial lung abnormalities are associated with an increased risk of lung cancer. METHODS:Data from all participants in the National Lung Cancer Trial were analyzed, except for subjects with preexisting interstitial lung disease or prevalent lung cancers. The primary analysis included those who underwent low-dose CT imaging; those undergoing chest radiography were included in a confirmatory analysis. Participants with evidence of reticular/reticulonodular opacities, honeycombing, fibrosis, or scarring were classified as having interstitial lung abnormalities. Lung cancer incidence and mortality in participants with and without interstitial lung abnormalities were compared by using Poisson and Cox regression, respectively. RESULTS:Of the 25,041 participants undergoing low-dose CT imaging included in the primary analysis, 20.2% had interstitial lung abnormalities. Participants with interstitial lung abnormalities had a higher incidence of lung cancer (incidence rate ratio, 1.61; 95% CI, 1.30-1.99). Interstitial lung abnormalities were associated with higher lung cancer incidence on adjusted analyses (incidence rate ratio, 1.33; 95% CI, 1.07-1.65). Lung cancer-specific mortality was also greater in participants with interstitial lung abnormalities. Similar findings were obtained in the analysis of participants undergoing chest radiography. CONCLUSIONS:Asymptomatic interstitial lung abnormalities are an independent risk factor for lung cancer that can be incorporated into risk score models.

Background: Racial disparities in resection of non–small cell lung cancer (NSCLC) are well documented. Patient-level and system-level factors only partially explain these findings. Although physician-related factors have been suggested as mediators, empirical evidence for their contribution is limited. Objective: To determine if racial disparities in receipt of thoracic surgery persisted after patients had a surgical consultation and whether there was a physician contribution to disparities in care. Methods: The authors identified 19,624 patients with stage I-II NSCLC above 65 years of age from the Surveillance-Epidemiology and End-Results-Medicare database. They studied black and white patients evaluated by a surgeon within 6 months of diagnosis. They assessed for racial differences in resection rates among surgeons using hierarchical linear modeling. Our main outcome was receipt of NSCLC resection. A random intercept was included to test for variability in resection rates across surgeons. Interaction between patient race and the random surgeon intercept was used to evaluate for heterogeneity between surgeons in resection rates for black versus white patients. Results: After surgical consultation, black patients were less likely to undergo resection (adjusted odds ratio, 0.57; 95% confidence interval, 0.47–0.69). Resection rates varied significantly between surgeons (P<0.001). A significant interaction between the surgeon intercept and race (P<0.05) showed variability beyond chance across surgeons in resection rates of black versus white patients. When the model included thoracic surgery specifalization the physician contribution to disparities in care was decreased. Conclusions: Racial disparities in resection of NSCLC exist even among patients who had access to a surgeon. Heterogeneity between surgeons in resection rates between black and white patients suggests a physician’s contribution to observed racial disparities. Specialization in thoracic surgery attenuated this contribution.