Stereotactic body radiotherapy offered better 30-day mortality rates than surgery for patients with lung cancer who had severe chronic obstructive pulmonary disease, according to study results published in the International Journal of Radiation, Oncology, Biology, Physics.
To compare the outcome of patients with non–small cell lung cancer who had severe chronic obstructive pulmonary disease (COPD) and underwent stereotactic body radiotherapy vs. surgical intervention, researchers evaluated a single-institution cohort of 176 patients with stage III or IV COPD and stage I NSCLC.
In addition, the systematic review identified four other studies — two surgical (n=121) and two stereotactic body radiotherapy (n=75) — in which stereotactic body radiotherapy studies were found to be more recent and included older patients than surgical studies.
According to study results, the median follow-up was 21 months and median OS was 32 months — the severity of patient COPD was observed to be associated with OS (P=.01). In particular, the mean 30-day mortality rate for patients who received stereotactic body radiotherapy was 0% vs. 10% for patients who underwent surgery.
“[Stereotactic body radiotherapy] is associated with low risks of operative mortality, rarely requires a hospital stay, and is associated with a favorable toxicity profile,” the researchers said. “However, this review indicates that published data reporting survival outcomes in patients with severe COPD and stage I NSCLC are lacking.”
Study results indicated that stereotactic body radiotherapy achieved comparable long-term survival outcomes to surgical resection — 1-year OS for patients who received stereotactic body radiotherapy was 79% to 95%, whereas 1-year OS for surgical patients was 45% to 86%.
“[Stereotactic body radiotherapy] is a safe and effective less-invasive option for lung cancer patients with COPD that does not have the added risks of surgery-related mortality and prolonged hospitalization,” study researcher David Palma, MD, MSc, a radiation oncologist at the London Regional Cancer Program in London, Ontario, Canada, said in a press release. “All eligible patients should be evaluated in a multidisciplinary setting and afforded an informed decision of the risks and benefits of both surgery and [stereotactic body radiotherapy].”
Disclosure: The researchers report that the VU University Medical Center has a research collaboration with Varian Medical Systems.
Stereotactic body radiotherapy is the standard of care for patients with medically inoperable stage I NSCLC, providing an extremely effective alternative to surgery with minimal toxicity. While multiple operative risk stratification systems have been validated, there are no absolute universally accepted criteria for pulmonary inoperability. Management of the patient at the intersection of indications for surgery or stereotactic body radiotherapy is a challenge, given the lack of randomized comparative data and the substantial selection bias in the available comparative series.
The study by Dr. Palma and colleagues seeks to fill this gap with a combination of their own data and a systematic review of patients meeting accepted standard criteria for COPD.The primary conclusions of the study validate other early literature on this subject; when strict criteria are applied to limit selection bias between treatment groups, outcome measures appear to converge. A similar conclusion is suggested in a single-institution series (Crabtree TD. J Thorac Cardiovasc Surg. 2010;140:377-386) where differences in local control and OS in the unmatched analysis became nonsignificant after propensity matching. The current study also highlights differences in acute mortality favoring stereotactic body radiotherapy. A thought-provoking Markov model-based decision analysis by a group, including Dr. Palma (Louie A. Int J Radiat Oncol Biol Phys. 2011;81:964-973), similarly suggests a small advantage to surgery at baseline; however, better performance of stereotactic body radiotherapy as surgical risk increases (the model favors stereotactic body radiotherapy when perioperative risk exceeds 3.7%).
Overall, the authors are to be commended, as their comparison criteria are among the best presented to date, although still limited by inherent differences in the treatment populations. Ultimately, to reach a definitive conclusion, completion of the ongoing randomized trial, American College of Surgeons Oncology Group Z4099/ Radiation Therapy Oncology Group 1021, comparing sublobar resection to stereotactic body radiotherapy for high-risk patients is critical.
Kevin Stephans, MD
Taussig Cancer Institute
The Cleveland Clinic
Disclosure: Dr. Stephans reports that data from Cleveland Clinic was included in the systematic review reported in this study.