Video-assisted thoracoscopic lobectomy is associated with greater recurrence-free survival than stereotactic body radiotherapy for clinical stage I lung cancer

Comparison of Treatment Outcomes Between Thoracoscopic Surgery and Stereotactic Body Radiotherapy for Early-Stage Non-Small Cell Lung Cancer

Objective: To compare the risk of death, tumor recurrence, metastasis, and disease progression in early-stage non-small cell lung cancer (NSCLC) patients treated with thoracoscopic surgery and stereotactic body radiotherapy (SBRT). Methods: Patients who underwent radical surgery and SBRT for NSCLC between April 2010 and November 2021 were retrospectively analyzed. Continuous and categorical variables were compared using the Mann-Whitney U and Chi-square test, respectively. Kaplan-Meier curves were used to evaluate the survival outcomes of each patient group. Cox proportional hazard regression analyses were performed to estimate the risk of death, tumor recurrence, metastasis, and disease progression. Results: A total of 167 patients were enrolled, of whom 75 and 92 underwent SBRT and surgery, respectively. The median follow-up was 45 months (range, 4-105 months). SBRT patients were observed to be significantly older (median, 76.0 vs 67.0 years; P < .001), and associated with significantly higher mortality rate (42.7% vs 26.1%, P = .024). However, no significant difference in overall survival duration was seen between the SBRT and surgery groups (45.0 vs 41.0 months; P = .199). SBRT patients demonstrated significantly lower rates of metastasis (12.0% vs 30.4%, P = .004), and significantly longer metastasis-free survival (39.0 months vs 35.5 months, P = .020). The remaining outcomes, including tumor recurrence and disease progression rates, were similar between the groups. Compared to surgery, SBRT did not significantly associate with death, recurrence, or disease progression. Kaplan-Meier curves showed significant differences in overall, tumor recurrence-free, and disease progression-free survival between the groups (log-rank P < .05). Conclusions: SBRT demonstrated similar overall survival compared to radical surgery, and associated with significantly reduced risk of tumor metastasis. Our study thereby suggests SBRT as the best treatment option for patients with inoperable NSCLC.

Stereotactic Body Radiation Therapy Versus Ablation Versus Surgery for Early-Stage Lung Cancer in High-Risk Patients

Current treatment for early-stage lung cancer focuses on surgical intervention as the mainstay of treatment; however, this poses issues in patients that are high-risk or unable to tolerate any operation. In this case, sublobar resection or radiation therapy has been the primary treatment for these subsets of patients. Alternative approaches include stereotactic body radiation therapy (SBRT) and thermal ablation. In this article, we focus on treatment strategies using SBRT, thermal ablation, or surgery as it pertains to high-risk patients with early-stage lung cancer.

Surgical resection versus radiotherapy for clinical stage IA lung cancer ≤1 cm in size: A population-based study

OBJECTIVE

With the increasing incidence of stage IA lung cancer ≤1 cm in size, the optimal primary treatment remains to be controversial, and thus, we compared the survival of these patients treated with radiotherapy, wedge resection, segmentectomy, or lobectomy in a large population.

METHODS

We identified patients with stage IA lung cancer ≤1 cm in size between 2004 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We compared the overall survival (OS) via Kaplan-Meier analysis and conducted Cox regression analysis via propensity score matching (PSM) method to identify the relative hazard ratio (HR) and difference of OS among these treatments in the subgroup stratified by four variables (age, total number of tumors, pathological grade, and histology).

RESULTS

A total of 5435 patients were included with a median age of 68 years (range, 6-94 years), of which 2131 (39.2%) were male, and 3510 (64.6%) were adenocarcinoma. The 5-year OS rate was 67.1%, 34.5%, 61.6%, 72.1%, and 75.0% for the entire study population, radiotherapy, wedge resection, segmentectomy, and lobectomy, respectively. In PSM analysis, wedge resection and segmentectomy were all superior to radiotherapy (P < 0.001), and segmentectomy was superior to wedge resection (P = 0.043), while segmentectomy was comparable with lobectomy (P = 0.058). In patients with multiple tumors, radiotherapy brought similar survival to surgery (wedge resection versus radiotherapy, P = 0.323; segmentectomy versus radiotherapy, P = 0.170; lobectomy versus radiotherapy, P = 0.796).

CONCLUSIONS

Among stage IA lung cancer with ≤1 cm, segmentectomy and lobectomy were identified as the potential effective treatments, with segmentectomy more preferred, while radiotherapy would be recommended in those with multiple tumors, which requires further verification.

Application of bilateral simultaneous sequential single-incision video-assisted thoracic surgery in multiple nodules both lungs: a single-center experience of 10 cases

Objective

To discuss the application of bilateral simultaneous sequential single-incision video-assisted thoracic surgery in multiple nodules in both lungs.

Methods

A retrospective analysis of 10 patients in Zhengzhou People’s Hospital who underwent single-incision thoracoscopic surgery to treat multiple nodules in both lungs at the same time from September 2019 to January 2021, and analyze the perioperative indicators (general condition, smoking history, family history, follow-up time of pulmonary nodules, size, location, height and weight, pulmonary function, intraoperative blood loss, operation time, color and volume of drainage fluid, catheterization time, perioperative complications, length of stay, pathology, patient satisfaction, etc.).

Results

All 10 patients used single-incision thoracoscopy to complete bilateral simultaneous sequential operations, aged 32 to 70 years, 8 female patients, 2 male patients, preoperative follow-up time ranging from 1 day to 2 years, a total of 23 lung nodules were removed except for the benign lesions in one nodule in the 2 patients, the other nodules were tumorous lesions (91.3%). The average total hospital stay was 10.5 days (8–14 days), and the average operation time was 194.5 min (145–292 min). The blood loss ranged from 10 to 280 ml, all patients had no serious complications during the perioperative period, and they recovered well and were discharged smoothly, and the satisfaction reached 100%.

Conclusion

Single-incision bilateral simultaneous sequential thoracoscopy have certain advantages in the treatment of patients with multiple nodules in both lungs, conforms to the concept of rapid recovery, and is a feasible choice in the shared decision making of doctors and patients.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 4: systematic review of evidence involving SBRT and ablation

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after SBRT or thermal ablation vs. resection is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

Short-term outcomes are meaningfully better after SBRT than resection. SBRT doesn't affect quality-of-life (QOL), on average pulmonary function is not altered, but a minority of patients may experience gradual late toxicity. Adjusted non-randomized comparisons demonstrate a clinically relevant detriment in long-term outcomes after SBRT vs. surgery. The short-term benefits of SBRT over surgery are accentuated with increasing age and compromised patients, but the long-term detriment remains. Ablation is associated with a higher rate of complications than SBRT, but there is little intermediate-term impact on quality-of-life or pulmonary function tests. Adjusted comparisons show a meaningful detriment in long-term outcomes after ablation vs. surgery; there is less difference between ablation and SBRT.

Conclusions

A systematic, comprehensive summary of evidence regarding Stereotactic Body Radiotherapy or thermal ablation vs. resection with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

Stereotactic body radiotherapy versus surgery for early-stage non-small cell lung cancer: an updated meta-analysis involving 29,511 patients included in comparative studies

Objective:

To evaluate the efficacy of stereotactic body radiotherapy (SBRT) versus surgery for early-stage non-small cell lung cancer (NSCLC) by means of a meta-analysis of comparative studies.

Methods:

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines, searches were performed on PubMed, MEDLINE, Embase, and Cochrane Library for eligible studies. The meta-analysis compared the hazard ratios (HR) for overall survival (OS), cancer-specific survival (CSS), and local control (LC). Subgroup and meta-regression analyses evaluated the association of extent of surgical resection, study publication year, tumor staging, propensity score matching, proportion of chemotherapy use, and proportion of pathological lymph node involvement with CSS and OS.

Results:

Thirty studies involving 29,511 patients were included (surgery group: 17,146 patients and SBRT group: 12,365 patients). There was a significant difference in favor of surgery vs. SBRT in the 3-year OS (HR = 1.35; 95% CI: 1.22-1.44; I² = 66%) and 3-year CSS (HR = 1.23; 95% CI: 1.09-1.37; I² = 17%), but not in the 3-year LC (HR = 0.97; 95% CI: 0.93-1.08; I² = 19%). In the subgroup analysis for OS, no significant difference between surgery and SBRT groups was observed in the T1N0M0 subgroup (HR = 1.26; 95% CI: 0.95-1.68; I² = 0%). In subgroup analysis for CSS, no significant difference was detected between the sublobar resection subgroup and the SBRT group (HR = 1.21; 95% CI: 0.96-1.53; I² = 16%).

Conclusions:

Surgery generally resulted in better 3-year OS and CSS than did SBRT; however, publication bias and heterogeneity may have influenced these findings. In contrast, SBRT produced LC results similar to those of surgery regardless of the extent of surgical resection. These findings may have important clinical implications for patients with comorbidities, advanced age, poor pulmonary reserve, and other factors that may contraindicate surgery.

Comparison of stereotactic body radiotherapy and radiofrequency ablation for early-stage non-small cell lung cancer: a systematic review and meta-analysis

Background

Stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) are recommended for patients with inoperable early-stage non-small cell lung cancer (NSCLC), with both offering promising results. However, it is largely unknown which of these two treatment modalities provides superior benefits for patients. Therefore, this systematic review and meta-analysis compared clinical outcomes and safety between SBRT and RFA in patients with inoperable early-stage NSCLC.

Methods

Eligible studies published between 2001 and 2020 were obtained through a comprehensive search of the PubMed, Medline, Embase, and Cochrane Library databases. Original English-language studies on the treatment of early-stage NSCLC with SBRT or RFA were included. Local control (LC) rates, overall survival (OS) rates, and adverse events were obtained by pooled analyses.

Results

Eighty-seven SBRT studies (12,811 patients) and 18 RFA studies (1,535 patients) met the eligibility criteria. For SBRT, the LC rates (with 95% confidence intervals) at 1, 2, 3, and 5 years were 98% (97-98%), 95% (95-96%), 92% (91-93%), and 92% (91-93%), respectively, which were significantly higher than those for RFA [75% (69-82%), 31% (22-39%), 67% (58-76%), and 41% (30-52%), respectively] (P<0.01). There were no significant differences in short-term OS between SBRT and RFA [1-year OS rate: 87% (86-88%) versus 89% (88-91%), P=0.07; 2-year OS rate: 71% (69-72%) versus 69% (64-74%), P=0.42]. Regarding long-term OS, the 3- and 5-year OS rates for SBRT were 58% (56-59%) and 39% (37-40%), respectively, which were significantly (P<0.01) superior to those for RFA [48% (45-51%) and 21% (19-23%), respectively]. The most common complication of SBRT was radiation pneumonitis (grade ≥2), making up 9.1% of patients treated with SBRT, while pneumothorax was the most common complication of RFA, making up 27.2% of patients treated with RFA.

Discussion

Compared with RFA, SBRT has superior LC and long-term OS rates but similar short-term OS rates. Prospective randomized trials with large sample sizes comparing the efficacy of SBRT and RFA are warranted.

Impact of Genetic Polymorphisms on the Metabolic Pathway of Vitamin D and Survival in Non-Small Cell Lung Cancer

Vitamin D has been associated with risk, development, and progression of cancer. However, the genes involved in its metabolism are highly polymorphic, compromising its activity. The aim of this study is to evaluate the association between the gene polymorphisms involved in the metabolic pathway of vitamin D and survival in patients with non-small-cell lung cancer (NSCLC). The study was designed as an observational cohort which included 194 Caucasians patients from southern Spain with NSCLC. Real-time polymerase chain reaction was used to analyze the following polymorphisms: CYP27B1 rs4646536, rs3782130, and rs10877012; CYP24A1 rs6068816 and rs4809957; GC rs7041; CYP2R1 rs10741657; VDR rs1544410 (BsmI), rs11568820 (Cdx-2), rs2228570 (FokI), rs7975232 (ApaI), and rs731236 (TaqI). Progression-free survival (PFS) and overall survival were assessed. Cox regression showed that rs4646536 was associated with PFS in the general population (p = 0.0233) and in the non-resected NSCLC subgroup (p = 0.0233). In the resected NSCLC subgroup, rs11568820 was associated with OS (p = 0.0129) and rs7041 with PFS (p = 0.0447). In the non-resected NSCLC subgroup, rs6068816 was associated with PFS (p = 0.0048) and OS (p = 0.0089) and rs731236 and rs7975232 were associated with OS (p = 0.0005) and PFS (p = 0.0002), respectively. The other polymorphisms showed no effect on the results. The rs4646536, rs6068816, rs7041, rs11568820, rs731236, and rs7975232 polymorphisms are associated with survival in NSCLC and may have a substantial role as prognostic markers of the disease.

Stereotactic ablative radiotherapy versus surgery in older patients with stage I lung cancer

OBJECTIVES

Surgical resection is the best option for the treatment of early-stage lung cancer. However, older patients are less likely to receive curative treatment. Therefore, we compared long-term survival rates between surgical resection and stereotactic ablative radiotherapy (SABR) for the treatment of early-stage lung cancer in older patients.

METHODS

From 2013 to 2016, 272 patients aged ≥75 years with clinical stage I lung cancer underwent surgical resection (n = 191) or SABR (n = 81). A propensity score-matched analysis was performed. Overall survival, cumulative incidence of cancer-related death and recurrence were compared between the 2 groups.

RESULTS

In the matched cohort, 48 well-balanced pairs were extracted. An overall survival benefit was associated with surgery (surgery vs SABR = 65.9% vs 40.3%; P = 0.034); however, there was no significant difference in the cumulative incidence of cancer-related death (P = 0.089) or recurrence (P = 0.111) between the 2 groups. Systemic dissemination was the dominant pattern of progression in both groups. The 3-year cumulative incidence of regional recurrence was significantly higher in the SABR group compared to the surgery group (surgery vs SABR = 0% vs 11.4%, P = 0.046).

CONCLUSIONS

Surgical resection with mediastinal lymph node dissection provides better long-term survival compared to SABR in older patients with stage I lung cancer. Surgery should be considered for older patients aged ≥75 years who are appropriate candidates for surgery. SABR remains an alternative treatment with comparable cancer-related death and recurrence for patients unsuitable for surgery.

A propensity-matched analysis of stereotactic body radiotherapy and sublobar resection for stage I non-small cell lung cancer in patients at high risk for lobectomy: the results in a Chinese population

Background

To investigate the comparative effectiveness of stereotactic body radiotherapy (SBRT) and sublobar resection (SLR) in patients with stage I non-small cell lung cancer (NSCLC) considered to be high-risk lobectomy patients.

Methods

From January 2012 to December 2015, patients who underwent SBRT or SLR for clinical stage I NSCLC were examined retrospectively. Propensity score matching (PSM) was performed to reduce selection bias in SBRT and SLR patients.

Results

Data from 86 SBRT and 79 SLR patients was collected. Median follow-up periods of the SBRT and SLR groups were 32 and 37 months, respectively. Patients treated with SBRT exhibited significantly higher age, higher likelihood of being male, larger tumor diameter, lower forced expiratory volume in 1 second (FEV1), and poorer performance status compared with SLR patients. There were no significant differences between SBRT and SLR patients for 3-year overall survival (OS) (80.3% and 82.3%, P=0.405), cause-specific survival (CSS) (81.3% and 83.4%, P=0.383), and local control (LC) (89.7% and 86.0%, P=0.501). Forty-nine patients were identified from each group after performing PSM. After patients were matched for age, gender, performance status, tumor characteristics and pulmonary function, no significant differences were observed in 3-year OS (85.4% and 73.3%, P=0.649), CSS (87.2% and 74.9%, P=0.637) and LC (95.6% and 82.1%, P=0.055). Prevalence of significant adverse events (grade 3 or worse) was 0% and 10.2% in the matched SBRT and SLR groups (P=0.056), respectively.

Conclusions

Disease control and survival in the SBRT patients was equivalent to that seen in SLR patients with stage I NSCLC considered high-risk lobectomy candidates. SBRT could therefore be an alternative option to SLR in treating patients with a high operative risk.

Video-Assisted Thoracoscopic Lobectomy Versus Stereotactic Body Radiotherapy Treatment for Early-Stage Non-Small Cell Lung Cancer: A Propensity Score-Matching Analysis

Background

Compared the overall outcomes of video-assisted thoracoscopic surgery (VATS) versus stereotactic body radiotherapy (SBRT) for stage I-II non-small cell lung cancer (NSCLC).

Methods

We retrospectively compared overall survival (OS), cancer-specific survival (CSS), locoregional control (LRC), and disease-free survival (DFS) at our institution between January 2012 and December 2016. Propensity score-matching was performed to reduce patient selection bias based on age, gender, Karnofsky performance score, Charlson comorbidity index, pulmonary function, and tumor diameter.

Results

A total of 567 patients treated with SBRT (n = 109) or surgery (n = 458) were included. Of those, 104 patients were matched for further analyses. Median follow-up was 44 months. At 3 and 5 years, OS was 88.6 and 79.9% for SBRT, and 94.2 and 91.6% for surgery (p = 0.097). There were no differences noted in 5-year CSS (83.7 vs. 91.6%, respectively; p = 0.270). The cumulative incidence of LRC at 3 and 5 years was comparable (93.5 and 93.5% vs. 94.0 and 85.9%, respectively; p = 0.621). Differences in the rates of disease-free survival at 5 years were not statistically significant (79.0 and 80.5%, respectively; p = 0.624).

Conclusions

This propensity score-matching analysis suggests that SBRT can be an alternative option to VATS lobectomy for stage I-II NSCLC.

Choosing the right survey: the lung cancer surgery

Radical and palliative treatments for non-small cell lung cancer (NSCLC) have faced a significant evolution during last decades, which in turn has modified their effects on the patient quality of life (QoL). QoL data collection is becoming methodologically rigorous, with published recommendations and societal statements. In lung cancer surgery, there is no standardization in collecting and analyzing this outcome yet. However, to face the evolution in lung cancer therapies, few initiatives like the European Organization for the Research and Treatment of Cancer (EORTC) lung cancer module update project or the Patient-Reported Outcomes Measurement Information System (PROMIS), have now the potential to help thoracic surgeons to collect QoL data with validated dynamic instruments to make this outcome comparable to the clinical ones. This review aims to give an overview of the available and most commonly used QoL questionnaires in lung cancer surgery in order to facilitate future research and practical implementation.

The Quality of Peer-Reviewed Publications on Surgery for Early Stage Lung Cancer Within the Veterans Health Administration

The peer-reviewed literature is often referenced to generalize outcomes for lung cancer surgeries performed within the Veterans Health Administration (VHA) and include assessments following resection of early stage non-small-cell lung cancer (NSCLC). We sought to determine the reliability of these reports that are publicly available. A systematic review was undertaken to identify PubMed indexed articles that report postoperative outcomes following surgical resections for stage I NSCLC within the VHA. Only studies that reported American Joint Committee on Cancer staging were included. Eleven studies spanning 49 years (1966-2015) met the inclusion criteria. Two reported findings from national VHA databases while 9 reported outcomes from single institutions. Reporting of outcomes and prognostic factors varied widely between studies and were frequently omitted. This made it difficult to evaluate prognostic factors that may be associated with a wide range of 30- and 90-day perioperative mortality (0-3.8% and 0-6.4%), 3- and 5-year cause-specific survival (72-92% and 32-84%), and 3- and 5- year overall survival (47-85.7% and 24-74%). The quality of peer-reviewed literature that reports outcomes following thoracic surgery for stage I NSCLC in the VHA is inconsistent and precludes accurate assessments for generalizations about the quality of care in this healthcare system. Efforts to develop a dedicated outcome tracking and registry system can provide more meaningful evidence to identify areas for improvement for this often-curable malignancy.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Robotic Thoracic Surgery

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

Stereotactic Body Radiotherapy Versus Surgery for Early-Stage Non-Small-Cell Lung Cancer

BACKGROUND

Surgery is the gold standard therapy for patients with early-stage non-small-cell lung cancer (NSCLC). However, stereotactic body radiotherapy (SBRT) may provide as an alternative for patients who are medically inoperable or refuse surgical resection. The optimal treatment (SBRT or surgery) for patients with early-stage NSCLC is not clear.

METHODS

A systematic search was performed from PubMed, MEDLINE, Embase, and the Cochrane Library. Study heterogeneity and publication bias were estimated.

RESULTS

Fourteen cohort studies involving 1438 participants (719 who received SBRT and 719 who received surgery) were included in the meta-analysis. The main bias sources between the two groups, such as age, gender, tumor diameter, forced expiratory volume in 1 s, and Charlson comorbidity index were matched. The surgery was associated with a better overall survival (OS) and long-term distant control (DC) for early-stage NSCLC. The pooled OR and 95% confidence interval (CI) for 1-y, 3-y, 5-y OS, and 5-y DC were 1.56 (1.12-2.15), 1.86 (1.50-2.31), 2.43 (1.80-3.28), and 2.74 (1.12-6.67), respectively. No difference was found between the treatments in the 1-y and 3-y disease-free survival; 1-y, 3-y and 5-y locoregional control; or 1-y and 3-y DC.

CONCLUSIONS

Our results found a superior OS and long-term DC for early-stage NSCLC after surgery compared with SBRT after propensity score matching.

Bronchoscopic ablation of peripheral lung tumors

Lung cancer is the leading cause of cancer-related death worldwide and lobectomy remains the standard of care for patients with early-stage non-small cell lung cancer (NSCLC). The combination of an aging population and the implementation of low-dose CT for lung cancer screening is leading to an increase in diagnosis of early stage NSCLC in medically "inoperable" patients. The recommended treatment for this latter group of patients is stereotactic body radiation therapy (SBRT). However, many patients cannot undergo SBRT because they have received prior radiation or because the tumor is located next to vital structures. Percutaneous ablative therapies have become an alternative to SBRT but, unfortunately, they all violate the pleura and are associated with high rate of pneumothorax. With a more favorable safety profile and the ability to provide also diagnosis and nodal staging, bronchoscopic ablation is hence emerging as a potential future therapeutic alternative for these patients. Herein we review the current state of the art including animal and human data that exists thus far. We also discuss technical and research challenges as well as future directions that this exciting new technology may take.

Video-assisted thoracic lobectomy versus stereotactic body radiotherapy for stage I nonsmall cell lung cancer in elderly patients: a propensity matched comparative analysis

Comparative studies of the overall survival (OS) in elderly patients with nonsmall cell lung cancer (NSCLC) after surgery or stereotactic body radiotherapy (SBRT) have been limited by mixed extents of resection and different surgical approaches.

792 patients aged ≥65 years with clinical stage I NSCLC underwent video-assisted thoracic surgery (VATS) lobectomy or SBRT between 2010 and 2015. The propensity score-matched primary analysis included data from the full cohort; the secondary analysis included data from a subgroup of patients with data on pulmonary function.

Median OS for unmatched patients was 77 months for patients undergoing VATS lobectomy and 38 months for SBRT. The 1-, 3- and 5-year OS rates after VATS lobectomy were 92%, 76% and 65%, and after SBRT were 90%, 52% and 29% (p<0.001). Median OS for matched patients in the primary analysis was 77 months for patients undergoing VATS lobectomy and 33 months for SBRT. The 1-, 3- and 5-year OS rates after VATS lobectomy were 91%, 68% and 58%, and after SBRT were 87%, 46% and 29% (p<0.001). The survival advantage with VATS lobectomy persisted in the secondary analysis after adjusting for non-matched variables (p=0.034).

We suggest that elderly patients with stage I NSCLC undergoing VATS lobectomy have a better rate of OS than patients undergoing SBRT, irrespective of matching. This could be clinically important in decision-making for elderly patients who can tolerate surgery.

A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers

BACKGROUND

Advances in early diagnosis and curative treatment have reduced high mortality rates associated with non-small cell lung cancer. However, racial disparity in survival persists partly because Black patients receive less curative treatment than White patients.

METHODS

We performed a 5-year pragmatic, trial at five cancer centers using a system-based intervention. Patients diagnosed with early stage lung cancer, aged 18-85 were eligible. Intervention components included: (1) a real-time warning system derived from electronic health records, (2) race-specific feedback to clinical teams on treatment completion rates, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative treatment.

RESULTS

There were 2841 early stage lung cancer patients (16% Black) in the retrospective group and 360 (32% Black) in the intervention group. For the retrospective baseline, crude treatment rates were 78% for White patients vs 69% for Black patients (P < 0.001); difference by race was confirmed by a model adjusted for age, treatment site, cancer stage, gender, comorbid illness, and income-odds ratio (OR) 0.66 for Black patients (95% CI 0.51-0.85, P = 0.001). Within the intervention cohort, the crude rate was 96.5% for Black vs 95% for White patients (P = 0.56). Odds ratio for the adjusted analysis was 2.1 (95% CI 0.41-10.4, P = 0.39) for Black vs White patients. Between group analyses confirmed treatment parity for the intervention.

CONCLUSION

A system-based intervention tested in five cancer centers reduced racial gaps and improved care for all.

Survival After Stereotactic Body Radiation Therapy for Clinically Diagnosed or Biopsy-Proven Early-Stage NSCLC: A Systematic Review and Meta-Analysis

INTRODUCTION

Stereotactic body radiation therapy (SBRT) is a promising curative treatment for early-stage NSCLC. It is unclear if survival outcomes for SBRT are influenced by a lack of pathological confirmation of malignancy and staging of disease in these patients. In this systematic review and meta-analysis, we assess survival outcomes after SBRT in studies with patients with clinically diagnosed versus biopsy-proven early-stage NSCLC.

METHODS

The main databases were searched for trials and cohort studies without restrictions to publication status or language. Two independent researchers performed the screening and selection of eligible studies. Outcomes were overall survival, cancer-specific survival, and disease-free survival. The inverse variance method and the random effects method for meta-analysis were used to assess pooled survival estimates.

RESULTS

A total of 11,195 nonduplicate records were identified by the original search strategy. After screening by title and abstract, 1051 potentially eligible records were identified. A total of 43 articles were included. The comparative studies showed lower 3-year overall survival and lower 2-year and 5-year cancer-specific survival for biopsy-proven disease compared to clinical disease. However, 5-year overall survival was the same for both groups. For the pooled estimates, 3-year disease-free survival and 2-year cancer-specific survival were lower for biopsied disease.

CONCLUSIONS

Results of this systematic review and meta-analysis show a discrepancy in oncological outcomes for patients undergoing SBRT for suspected early-stage NSCLC in whom there is pathologic conformation of malignancy and those who there is only a clinical diagnose of NSCLC. These results emphasize the importance of obtaining pathologic proof of malignancy.

A systematic review and meta-analysis of stereotactic body radiation therapy versus surgery for patients with non-small cell lung cancer

OBJECTIVE

Stereotactic body radiation therapy is the preferred treatment modality for patients with inoperable early-stage non-small cell lung cancer. However, comparative outcomes between stereotactic body radiation therapy and surgery for high-risk patients remain controversial. The primary aim of the present meta-analysis was to assess overall survival in matched and unmatched patient cohorts undergoing stereotactic body radiation therapy or surgery. Secondary end points included cancer-specific survival, disease-free survival, disease recurrence, and perioperative outcomes.

METHODS

A systematic review of relevant studies was performed through online databases using predefined criteria. The most updated studies were selected for meta-analysis according to unmatched and matched patient cohorts.

RESULTS

Thirty-two studies were identified in the systematic review, and 23 were selected for quantitative analysis. Surgery was associated with superior overall survival in both unmatched (odds ratio, 2.49; 95% confidence interval, 2.10-2.94; P < .00001) and matched (odds ratio, 1.71; 95% confidence interval, 1.52-1.93; P < .00001) cohorts. Subgroup analysis demonstrated superior overall survival for lobectomy and sublobar resection compared with stereotactic body radiation therapy. In unmatched and matched cohorts, cancer-specific survival, disease-free survival, and freedom from locoregional recurrence were superior after surgery. However, stereotactic body radiation therapy was associated with fewer perioperative deaths.

CONCLUSIONS

The current evidence suggests surgery is superior to stereotactic body radiation therapy in terms of mid- and long-term clinical outcomes; stereotactic body radiation therapy is associated with lower perioperative mortality. However, the improved outcomes after surgery may be due at least in part to an imbalance of baseline characteristics. Future studies should aim to provide histopathologic confirmation of malignancy and compare stereotactic body radiation therapy with minimally invasive anatomical resections.