NON-SMALL CELL LUNG CANCER REPRESENTS the majority of lung cancer cases in the U.S., about 85%, and about 12% of all cancers. Treatment for early-stage lung cancers is typically surgery to remove the cancer or stereotactic body radiation therapy (SBRT), both of which deliver good results for many patients.
However, a new study suggests that surgery is superior to SBRT, at least in patients who are eligible for surgery.
In research presented at the May meeting of the American Association for Thoracic Surgery, researchers from the Yale University School of Medicine and New Haven Hospital compared patients who received surgery to treat stage I non-small cell lung cancer with patients who were eligible for surgery but elected to receive SBRT instead.
They looked at 30,658 patient records in the National Cancer Database, 24,729 who received surgery, and 5,929 who received SBRT, and matched the patients as closely as possible for variables such as age, tumor size and other health issues. The surgical patients had a five-year survival rate of 71.4%—meaning that 71.4% of the original study group were still alive five years after treatment—compared with a 55.9% five-year survival rate for patients who would have qualified for surgical treatment, be elected to undergo SBRT instead.
“It’s about a 15% difference at five years,” says study author and presenter Brooks Udelsman, a New Haven Hospital fellow in thoracic surgery at the time of the study and now an assistant professor of clinical surgery at the University of Southern California Keck School of Medicine in Los Angeles. While surgery can have greater risks and higher mortality early on, he adds, by about a year following treatment “you start to have better [results] than you do with SBRT.”
The study doesn’t mean SBRT is a poor treatment, Udelsman notes, and it is still the preferred option for patients who are not healthy enough to undergo surgery. But patients who can undergo surgery are more likely to survive longer than patients getting SBRT.
For many years, the standard of care for treating non-small cell lung cancer was only surgery, according to Mara Antonoff, a thoracic surgeon at the University of Texas MD Anderson Cancer Center in Houston. SBRT was brought in as a second option, she says, “after it was found to be a great solution for people who couldn’t receive surgery.”
Over time, there was an expansion of SBRT use to patients who qualified for surgery but chose SBRT instead for a variety of reasons, according to Udelsman, but many physicians felt without proof that SBRT wasn’t delivering the same results as surgery in those patients.
“We’ve always suspected that surgery is more effective,” but the study may now give physicians more confidence in recommending surgery for eligible patients, he says.
It’s important to note that SBRT is still an important treatment for many patients, according to Udelsman, since the risks inherent to surgery—it’s invasive, requires general anesthesia and removes a portion of the affected lung—may not be worth it for patients with other health conditions. And for patients with limited lung function, SBRT might be a safer option, he adds.
In some situations, a patient who is eligible for surgery might still choose SBRT, Udelsman says. “It’s basically done within a week; you don’t need to be hospitalized for it and you can get back to your life.”
“We physicians tend to think a lot about survival as the most important outcome to us, but that isn’t necessarily the most important outcome to every patient,” Antonoff says. “We need to be open to accepting those considerations.”
There were some limitations to the study, according to Antonoff, primarily that it was retrospective, looking at patient records from the past, rather than prospective, following new patients as they receive treatment. To date, there have been no prospective studies of surgery versus SBRT for non-small cell lung cancer where patients are randomly selected to get one treatment or the other, considered the gold standard for research, she says.
But the evidence is good enough to give Udelsman and Antonoff the confidence to say that all stage I non-small cell cancer patients should be informed of their options and, if eligible for surgery, be given an explanation of its long-term survival benefit compared with SBRT. In some cases, Antonoff says, that might be as simple as making sure patients talk to physicians from both surgical and radiation oncology specialties.
“It’s important that that decision about whether they are operative or not comes from a surgeon and not from a nonsurgeon,” she says. “And I think it’s very reasonable for a patient who needs a surgeon and is interested in SBRT to have the opportunity to meet with a radiation oncologist as well.”
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