Why are patients with non-small cell lung cancer in stage I-IIIA considered inoperable? A registry-based study from the capital region of Denmark

BACKGROUND: Surgical resection is first-line treatment for patients with stage I-IIIA non-small cell lung cancer (NSCLC), yet a substantial proportion are managed without surgery. The reasons for non-operative management and the role of objective functional assessment are insufficiently described. METHODS: This retrospective registry-based cohort study included patients diagnosed with stage I-IIIA NSCLC in 2022 in the Capital Region of Denmark. Data were retrieved from the Danish Lung Cancer Registry and electronic medical records. Patients were categorized into "Surgery" and "No surgery" groups. Demographic variables, lung function, ECOG performance status, comorbidities, and MDT justifications were extracted. Multivariable logistic regression identified factors associated with not receiving surgery, and one-year overall survival (OS) was estimated using Kaplan-Meier methods. RESULTS: Among 524 patients, 178 (34 %) did not undergo surgery. Non-surgical management was independently associated with age ≥ 80 years, stage IIIA disease, poorer ECOG performance status, comorbidities, and reduced or unregistered DLco, whereas FEV1 and DLco ≥ 80 % predicted were negatively associated. MDT justifications were low lung function or poor performance status (29.2 %), comorbidities (18.0 %), and N2 disease (11.8 %); in 19.7 % no justification was documented. No documentation of preoperative exercise testing was identified. One-year OS was higher after surgery than no surgery (95.7 % vs. 82.0 %), unadjusted. CONCLUSIONS: One third of patients with stage I-IIIA NSCLC were treated without surgery, mainly due to impaired functional status, comorbidity, or advanced stage. The absence of documented exercise testing highlights a gap between guideline recommendations and clinical practice.