January 02, 2018
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Surgery extends survival in early-stage lung cancer

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James D. Murphy

Lobectomy prolonged survival compared with stereotactic body radiation therapy for patients with early-stage lung cancer, according to study results published in The Annals of Thoracic Surgery.

“There are certainly patients who do benefit with radiation, especially those who wouldn’t be able to tolerate surgery,” James D. Murphy, MD, MS, chief of the gastrointestinal tumor service and chief of palliative radiation therapy in the department of radiation medicine and applied science at UC San Diego School of Medicine, told HemOnc Today. “[However], for patients who can tolerate surgery, surgery is still the standard of care.”

Surgery is the standard of care for patients with early-stage NSCLC, but a substantial number of patients cannot tolerate surgery owing to comorbidity. Over the past decade, SBRT has become the preferred treatment for this cohort.

Researchers used the Veterans Affairs Informatics and Computing Infrastructure to identify patients diagnosed with biopsy-proven stage I NSCLC between 2006 and 2015. Researchers compared survival among those who underwent lobectomy, sublobar resection or SBRT.

The analysis included 4,069 patients (mean age, 67 years; 96% men; 84% white), of whom 73% (n = 2,986) underwent lobectomy, 16% (n = 634) underwent sublobar resection and 11% (n = 449) received SBRT.

Patients who underwent SBRT group were older (mean age, 71 years vs 66 years) and had more comorbidities (mean Charlson comorbidity index score, 1.59 vs 1.33) than those who underwent surgery.

Median follow-up was 2.9 years for lobectomy, 2.6 years for sublobar resection and 1.5 years for SBRT.

Unadjusted analysis showed higher immediate postprocedural mortality among both surgery groups than the SBRT group. At 30-day follow-up, mortality was highest for lobectomy (1.9%), followed by sublobar resection (1.7%) and SBRT (0.5%), owing to operative risks.

However, 5-year incidence of cancer death appeared lowest among those who underwent lobectomy (23%), followed by sublobar resection (32%) and SBRT (45%).

Multivariable analysis showed SBRT appeared associated with a significant increased risk for cancer death compared with lobectomy (HR = 1.45; 95% CI, 1.09-1.94). Researchers observed no significant difference between SBRT and sublobar resection (HR = 1.25; 95% CI, 0.93-1.68).

Unadjusted 5-year OS was higher among patients who underwent lobectomy than SBRT (70% vs. 44%).

Use of SBRT increased throughout the study period, accounting for 2% of all treatment in 2006 to 19% in 2015.

“SBRT really came onto the scene maybe 10 to 15 years ago, and its use has gradually increased since then,” Murphy told HemOnc Today. “It’s a treatment option for patients who aren’t candidates for surgery, but really the reason we’re seeing an increase in use is because the technology has been more recently developed [compared with] surgery, which has been around for many years. There are a lot of patients who, unfortunately, are not candidates for surgery and we do treat them with SBRT.”

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Three clinical trials designed to compare surgery with SBRT have closed due to poor accrual, according to the researchers.

“With all medicine, the randomized trial is the gold standard that we shoot for when we try to compare two treatments,” Murphy said. “With this particular question of surgery vs. radiation, we don’t have really good randomized data. ...

“There are randomized trials going on that will hopefully accrue well and will hopefully have good results in the next several years,” he added. “As of now, I don’t think we really know the best treatment, although surgery remains the standard of care.” -- by Cassie Homer

 

Disclosures: Murphy reports no relevant financial disclosures. Please see the full study for all other authors’ relevant financial disclosures.