Surgery versus SABR for early stage non-small cell lung cancer: the moving target of equipoise

Abstract

The notion that lobectomy is the standard treatment approach for operable early stage non-small cell cancer (ES-NSCLC) was recently challenged by the results from a combined analysis of two prematurely closed randomized controlled trials (STARS and ROSEL trials; NCT00840749 and NCT00687986) (1). In this study, Chang et al. pooled data from 58 patients with operable T1-2a (<4 cm) N0M0 NSCLC treated with lobectomy versus stereotactic ablative radiotherapy (SABR) and reported a similar 3-year recurrence-free survival between the two modalities and a 3-year overall survival (OS) in favour of SABR. Despite the numerous limitations inherent to post-hoc analysis of studies with a small sample size, these results have cast doubt over the superiority of surgery and supported SABR as a valid alternate option in operable patients with ES-NSCLC.We No statistically significant differences were found in the 3-year loco-regional control (LRC) achieved with either SABR or surgery. Although the authors concluded that "lobectomy remains the best option for patients with stage I NSCLC who can tolerate it", several limitations should be kept in mind when interpreting these results. Specifically, in the era of personalized medicine, other factors not examined in this study such as health-related quality of life (HRQoL), costeffectiveness and treatment-related morality risk are highly relevant for optimal informed and shared decision-making.Despite accurate methodology and efforts to reduce bias by strict inclusion of only high quality studies using matched analysis, the meta-analysis by Deng et al. remains limited by a selection bias inherent to retrospective comparisons. In fact, while the process of matching allows for compensation in imbalances in baseline patients and tumours factors, the data presented are limited by the availability of various factors in the retrospective setting. This is highlighted by the significant heterogeneity of matched variables across the studies included in this meta-analysis. As examples, only one study matched patients based on tumor

Stereotactic ablative radiotherapy of 60 Gy in eight fractions is safe for ultracentral non‐small cell lung cancer

“…SABR is an effective treatment for patients with severe complications or pulmonary function who are unable to tolerate surgery. Using 4D‐CT and daily CT simulation to confirm the position and reduce deviation, SABR can deliver a high biological effective dose (BED) to the target while minimizing toxicity to the surrounding normal tissue, which may translate into improved LC and survival rate . With the progress of radiotherapy technology, SABR can be used to treat central lung cancer and even ultracentral lung cancer, which used to be risky to treat.…”

“…Using 4D-CT and daily CT simulation to confirm the position and reduce deviation, SABR can deliver a high biological effective dose (BED) to the target while minimizing toxicity to the surrounding normal tissue, which may translate into improved LC and survival rate. 10,16,17 With the progress of radiotherapy technology, • ≥Grade 2 radiation pneumonitis: 13.4%, 5.5%…”

Cost-effectiveness of stereotactic body radiation therapy versus video assisted thoracic surgery in medically operable stage I non-small cell lung cancer: A modeling study

“…A pooled analysis of two discontinued RCTs suggested equal effectiveness, although small sample size and short follow-up prohibited definitive conclusions [9]. The POSTLIV and VALOR RCTs on clearly operable NSCLC patients are expected to publish their results in 2026 [10].…”

Shared decision making in the treatment of stage I non small cell lung cancer—a choice which should equally involve both sides

“…However most recent studies dealing with the comparison of the two methods lead to the conclusion that surgery (lobectomy) remains the gold standard of treatment in patients with ES disease (11). Bahig et al emphasized the "moving target of equipoise", underlining the fact that health-related quality of life (HRQoL), costeffectiveness and treatment-related mortality risk may also be additional factors in comparing surgery and SABR (12). The article cites that in case of marginally operable patients SABR-, whereas in clearly operable patients lobectomy proved to be the most cost-effective option of treatment (13).…”