Surgery or radiotherapy for stage I lung cancer? An intention-to-treat analysis

Abstract

IntroductionSurgery is the standard of care for early-stage lung cancer, with stereotactic ablative body radiotherapy (SABR) a lower morbidity alternative for patients with limited physiological reserve. Comparisons of outcomes between these treatment options are limited by competing comorbidities and differences in pre-treatment pathological information. This study aims to address these issues by assessing both overall and cancer-specific survival for presumed stage I lung cancer on an intention-to-treat basis.MethodsThis retrospective intention-to-treat analysis identified all patients treated for presumed stage I lung cancer within a single large UK centre. Overall survival, cancer-specific survival, and combined cancer and treatment-related survival were assessed with adjustment for confounding variables using Cox proportional hazards and Fine–Gray competing risks analyses.Results468 patients (including 316 surgery and 99 SABR) were included in the study population. Compared with surgery, SABR was associated with inferior overall survival on multivariable Cox modelling (SABR HR 1.84 (95% CI 1.32–2.57)), but there was no difference in cancer-specific survival (SABR HR 1.47 (95% CI 0.80–2.69)) or combined cancer and treatment-related survival (SABR HR 1.27 (95% CI 0.74–2.17)). Combined cancer and treatment-related death was no different between SABR and surgery on Fine–Gray competing risks multivariable modelling (subdistribution hazard 1.03 (95% CI 0.59–1.81)). Non-cancer-related death was significantly higher in SABR than surgery (subdistribution hazard 2.16 (95% CI 1.41–3.32)).ConclusionIn this analysis, no difference in cancer-specific survival was observed between SABR and surgery. Further work is needed to define predictors of outcome and help inform treatment decisions.

Response to Letter to the Editor Titled “Surgery or Stereotactic Body Radiotherapy for Early Stage Lung Cancer: What is the Current Evidence?”

“…Patients in the lobectomy group were significantly younger (67.9 vs. 76.6 years) and more frequently in lower Global Initiative for Chronic Obstructive Lung Disease (GOLD) classes with a significantly better performance status. As Deng et al suggest, this imbalance between the 2 populations is reported by many other retrospective analyses 3 and may favor the survival in the surgery group. These limitations can be overcome only by randomized prospective trials.…”

Active Treatment Improves Overall Survival in Extremely Older Non–Small Cell Lung Cancer Patients: A Multicenter Retrospective Cohort Study

“…Another retrospective study compared surgery and radiation therapy among patients with stage I lung cancer using an intention-to-treat analysis [16]. In that paper, multivariable Cox modeling revealed inferior overall survival in the SBRT group to that of the surgery group.…”

Primary tumors of the lung: should we consider thermal ablation as a valid therapeutic option?

“…In a retrospective study [24] comparing 1102 patients treated with TA and 27,732 patients treated with SBRT, patients treated with TA had more comorbidities. This retrospective study also demonstrated that OS rates were comparable between TA and SBRT (1 year 85.4% vs. 86.3%, respectively, p ¼ .76; 2 years 65.2% vs. 64.5%, respectively, p ¼ .43; 3 years 47.8% vs. 45.9%, respectively, p ¼ .32; 5 years 24.6% vs. 26.1%, respectively, p ¼ .81).…”