Stereotactic Body Radiation Therapy Versus Nonradiotherapeutic Ablative Procedures (Laser/Cryoablation and Electrocautery) for Early-Stage Non–Small Cell Lung Cancer

Abstract

Background: Despite the fact that stereotactic body radiation therapy (SBRT) is the only recommended first-line therapy for inoperable early-stage non–small cell lung cancer (NSCLC), several thermal ablative procedures (TAPs; defined herein as laser/cryoablation and electrocautery) are available. Studies showing outcomes of these procedures and how they compare with SBRT are scarce. We sought to evaluate the comparative efficacy of SBRT versus TAPs using the National Cancer Database (NCDB). Methods: The NCDB was queried for patients with early-stage NSCLC who did not undergo surgical resection. Treatment-specific inclusion criteria were applied to select for patients receiving either TAPs or SBRT. Univariate logistic regression and Cox proportional hazards modeling were performed, and Kaplan-Meier curves were generated. Serial propensity matches were performed using a modified greedy 8→n matching 1:1 algorithm. Results: A total of 27,734 patients were analyzed; 26,725 underwent SBRT and 1,009 underwent TAPs. Patients who received SBRT were older and more likely to have clinical stage IB (vs IA) disease. Despite this, SBRT was associated with longer median overall survival (mOS; 37.7 vs 33.5 months; P=.001) and 1-, 2-, and 5-year OS rates compared with the TAPs cohort (86.7% vs 83.1%, 67.5% vs 62.7%, and 30.6% vs 26.9%, respectively; P=.001). Upon propensity matching, improved OS with SBRT remained, with a mOS of 40.4 versus 33.4 months and 1-, 2-, and 5-year OS rates of 89.0% versus 82.9%, 69.7% versus 62.7%, and 34.4% versus 26.4%, respectively (P=.003). Conclusions: Despite being associated with more higher-risk factors, SBRT was associated with higher OS compared with TAPs for treatment of nonoperative patients diagnosed with early-stage NSCLC. However, causation cannot be implied owing to the inherent limitations of large heterogeneous datasets such as the NCDB.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation—part 4: systematic review of evidence involving SBRT and ablation

“…Similar frequencies were noted in smaller prospective studies (86,87,138). Larger series report a 30-day mortality of 0.3-0.5% (134)(135)(136); but 90-day mortality was 3.8% in a large study (NCDB, 2004-14, 1,009 ablation patients) (139).…”

“…Adjusted NRCs (Table 7 and Figure S4-6) (59,(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149) demonstrate worse long-term outcomes after ablation than resection. The differences appear larger than for SBRT vs. resection (Table 1), but studies are limited and residual confounding makes interpretation difficult.…”

Stereotactic Radiation for Lung Cancer: A Practical Approach to Challenging Scenarios

“…20 It provides improved local control and overall survival (OS) compared with conventionally fractionated radiotherapy 9 and thermal ablation therapies, such as cryoablation and radiofrequency ablation. 25,26 Unfortunately, SBRT-related toxicity is higher in patients with ILD, and higher toxicity risk often correlates with higher ILD-GAP scores. A systematic review of mostly retrospective series reported an average incidence of grade greater than or equal to 3 radiation pneumonitis of 25% and treatment-related mortality of 16%.…”

Percutaneous Image-Guided Ablation of Lung Tumors

“…However, a retrospective comparison between various thermal ablation techniques and SBRT for stage I NSCLC using data from the National Cancer Database (NCDB) found no significant difference in overall survival rate but a higher rate of adverse effects in thermal ablation patients [31]. Another study using the NCDB reported a slightly lower overall survival rate for stage I NSCLC treated with various thermal ablation techniques compared to SBRT (33.5 vs. 37.7 months) [32]. Because of how ablations are coded in the NCDB, the studies could not determine outcomes for each of the techniques individually, which may vary significantly (Table 1).…”