Optimizing Pre-operative Clinical Staging in Resectable Non-Small Cell Lung Cancer: A Retrospective Cohort Study

Background: Accurate pre-operative clinical staging is vital for guiding treatment decisions in resectable non-small cell lung cancer (NSCLC). Discrepancies between clinical and pathological stages raise concerns about treatment appropriateness. Objective: The objective of the study is to determine the accuracy of the pre-operative clinical stage (cTN) with the post-operative pathological stage (pTN), examine factors predictive of inaccurate staging and explore the impacts on survival. Patient and Methods: This retrospective cohort study in Melbourne, Australia, analyzed stage I-IIIA NSCLC patients between 2011-2020. Primary exposures were pre-operative clinical stage (CT, PET, nodal evaluation) and post-operative pathological stage. The primary outcome was stage concordance between clinical and pathological stages of resected NSCLC. Various patient, tumour and surgical characteristics and quality of care metrics were collected from medical records. Logistic regression and COX proportional hazards regression assessed factors influencing staging concordance and survival. Results: Among 221 patients, 58% showed overall staging concordance. Discordance (42%) frequently led to upstaging (23.9%) or downstaging (17.2%) at pathology. Nodal stage concordance was influenced by female sex, SUV max, histology, and timing between CT and surgery. Nodal stage discordance independently correlated with higher mortality risk (p = 0.002, HR 2.37). Conclusions: The results of our study indicate inconsistencies between clinical methods of staging and pathological stages of NSCLC. Further optimization of clinical staging is essential for patients to receive guideline-concordant treatment. Pathological upstaging provides a significant safety risk and can result in adverse survival outcomes.