The American Society of Clinical Oncology–endorsed American Society for Radiation Oncology Evidence-Based Guideline of stereotactic body radiotherapy for early-stage non–small cell lung cancer: An expert opinion

Abstract

Feature Editor's Note-After reading this Feature Expert Opinion, it should be more evident than ever that lobectomy is the current standard of care for patients with stage I non-small cell lung cancer (NSCLC) who are medically fit for operation. It is common, however, for fit patients with stage I NSCLC to perceive stereotactic body radiotherapy (SBRT) as an attractive option for the treatment of their disease. SBRT is a noninvasive, well-tolerated outpatient procedure, and the Internet is replete with favorable efficacy statistics for SBRT that cannot be appropriately interpreted without a certain background in the field. As is common with all new and exciting technologies, innovation is provided with an opportunity to outpace the standard of care. SBRT for NSCLC is a relatively young and rapidly evolving modality of radiotherapy that has shown favorable results for control of the localized tumor mass in patients with stage I lung cancer who are not candidates for surgery. Consideration of SBRT to treat patients with stage I NSCLC who are medically fit for operation has resulted in the launching of 3 randomized controlled clinical trials (ROSEL, STARS, ACOSOG Z4099) comparing lobectomy with SBRT for operable stage I NSCLC, each of which closed prematurely because of poor accrual. In the absence of randomized data, 2 bodies of lower-level evidence literature on the comparative efficacies of surgery and SBRT for stage I lung cancer have emerged, one from the surgical community and one from the radiation oncology community. Sampling articles from each side of the aisle is an educational exercise that will benefit the reader's understanding of the disparities in outcomes reporting between each discipline and their implications for interpretation of results. Recently, the American Society for Radiation Oncology (ASTRO) published a refreshing evidence-based guideline on the role of SBRT in early stage NSCLC that was endorsed by the American Society of Clinical Oncology (ASCO). According to these guidelines, SBRT is not recommended as an alternative to surgery for patients with stage I NSCLC and standard operative risk, outside the context of a clinical trial. The Feature Expert Opinion article that follows is an interdisciplinary collaboration of surgery, radiation oncology, and pulmonology that will prime the readers on the most salient aspects of the ASTRO and ASCO guidelines for SBRT and offers a practical perspective for implementing these guidelines into practice. Bryan M. Burt, MDWe have witnessed controversies within the thoracic oncology community about the optimal treatment of early-stage non-small cell lung cancer (NSCLC), for which surgical lobectomy is challenged by stereotactic body radiotherapy (SBRT), and in the absence of randomized controlled trials, thoracic surgeons and radiation oncologists interpreted the available data in different ways. Therefore, the American Society for Radiation Oncology generated an evidence-based guideline on the role of SBRT in early-stage NSCLC: This guideline was From the

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“…For stage I disease, a 5-year survival rate of 75–80% can be obtained after successful surgery [ 1 ]. Radiosurgery can be performed, achieving comparable efficacy to surgery using the latest linear accelerator (LINAC) [ 30 ]. Stage II lung cancer is reached when the cancer has metastasized to the hilar lymph node (N1) or when it is a large tumor without lymphatic metastases (T2b-3N0).…”

Stereotactic radiotherapy for early-stage non-small cell lung cancer

“…According to the American Society of Clinical Oncologists [30] , for patients with standard operative risk (1.5% mortality rate) and Stage I NSCLC, SBRT is not recommended as an alternative to surgery outside clinical trials. The standard operative risk reached 4.4% in patients aged 81 years or more, even though age, sex, cardiovascular and pulmonary comorbidities, and patients' functional status are factors influencing peri-operative risk.…”

Radiomics for Prediction of Radiation-induced Lung Injury After Robotic Stereotactic Body Radiotherapy of Lung Cancer: Results From Two Independent Institutions

“…Stereotactic body radiation therapy (SBRT) is an effective therapy for early-stage, node-negative, medically inoperable non-small cell lung cancer (NSCLC). Dose-fractionation schemes usually depend on tumor size and location and have been largely standardized by current guidelines [1][2][3][4]. However, after irradiation, about 10-15% of the tumors will recur locally and up to 50% of the patients will experience systemic disease progression despite PET-based staging before SBRT [5].…”