Lobectomy Outperforms Stereotactic Body Radiation Therapy In Early-Stage Lung Cancer

Stereotactic body radiation therapy (SBRT), which uses higher doses, fewer fractions, and highly conformal beams compared with conventional radiation therapy, has been proposed as an alternative to surgery in operable patients with early-stage lung cancer. However, a newly published retrospective study in The Annals of Thoracic Surgery found that lobectomy improved survival in patients with early-stage lung cancer compared with SBRT.

The researchers, led by Alex K. Bryant of the School of Medicine at the University of California, San Diego, identified patients with biopsy-proven, clinical stage I non—small cell lung cancer using the Veteran’s Affairs (VA) Informatics and Computing Infrastructure, a system that captures approximately 90% of incident cancers within the VA system. They then compared cancer-specific survival among patients (n = 4069) who received lobectomy (n = 2986), sublobar resection (n = 634), or SBRT (n = 449). Comparisons of cancer-specific survival among treatment groups were performed with a competing risk analysis to account for the risk of non-cancer mortality.

The researchers found that the 5-year unadjusted cumulative incidence of cancer death was lowest in the lobectomy group at 23%, followed by the sublobar group (32%) and the SBRT group (45%). Additionally, SBRT was associated with a 45% increase in the risk of cancer death compared with lobectomy (sub-distribution hazard ratio: 1.45; 95% CI, 1.09-1.94). Multivariable analysis found no significant difference between SBRT and sublobar resection.

Both surgical groups had higher procedure-related mortality compared with the SBRT group, however: 30-day and 90-day mortality, respectively, were 1.9% and 3.6% for lobectomy; 1.7% and 2.5% for sublobar resection; and 0.5% and 1.4% for SBRT.

Despite the higher postoperative mortality risk, the lobectomy group had the lowest unadjusted risk of all-cause mortality at 5 years, with unadjusted 5-year overall survival (OS) at 70% (compared with lobar resection at 56% and SBRT at 44%).

The authors note that their findings are at odds with the pooled analysis of randomized trials comparing lobectomy with SBRT, which found 3-year OS of 95% in patients receiving SBRT versus 79% of patients undergoing lobectomy. Ultimately, prospective randomized studies will be necessary to further clarify whether radiation or surgery is more effective in patients with early-stage lung cancer.

“Our data suggest that the more aggressively we treat early lung cancer, the better the outcome,” said Bryant in a statement. “This study is one of the best-powered and detailed analyses to date and suggests that lobectomy is still the preferred treatment of this disease for most patients.”