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. 2020 Jul;110(1):228-234.
doi: 10.1016/j.athoracsur.2020.01.073. Epub 2020 Mar 5.

Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer

Rhami Khorfan  1 , Timothy J Kruser  2 , Julia M Coughlin  3 , Ankit Bharat  4 , Karl Y Bilimoria  1 , David D Odell  5
Affiliations

Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer

Rhami Khorfan et al. Ann Thorac Surg. 2020 Jul.

Abstract

Background: Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT.

Methods: The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression.

Results: We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01).

Conclusions: Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.

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Figures

Figure 1.
Figure 1.
Trend in refusing physician-recommended surgery and electing primary stereotactic body radiation therapy (SBRT).
Figure 2.
Figure 2.
Kaplan-Meier survival for propensity-matched analysis of surgery vs stereotactic body radiation therapy (SBRT) for operable early-stage non-small cell lung cancer. Propensity matched on age, sex, race/ethnicity, T stage, insurance status, income, Charlson comorbidity score, hospital type, hospital lung cancer volume, and year of diagnosis. Log-rank P < .001.
Figure 3.
Figure 3.
Sensitivity analyses of survival after surgery and stereotactic body radiation therapy (SBRT) for operable early-stage non-small cell lung cancer in selected subgroups. The propensity-match and Kaplan-Meier analysis were repeated with several modifications, including (a) only wedge resections in the surgical cohort, (b) only T1 tumors, (c) only patients aged <80 years treated after 2010, and (d) with an exact match on treating hospital. Log-rank P < .01 for all analyses.
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References

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