Stereotactic Ablative Radiotherapy Achieves Better Overall Survival Than Surgery in Stage I NSCLC
Patients with operable stage I non–small cell lung cancer (NSCLC) could achieve better overall survival rates if treated with stereotactic ablative radiotherapy rather than the invasive surgery, the current standard of care, according to research from a phase III randomized international study from The University of Texas MD Anderson Cancer Center. The findings, published by Chang et al in The Lancet Oncology, are from the first randomized clinical trials comparing stereotactic ablative radiotherapy and surgery.
“For the first time, we can say that the two therapies are at least equally effective, and that stereotactic ablative radiotherapy appears to be better tolerated and might lead to better survival outcomes for these patients,” said the first author and principal investigator Joe Y. Chang, MD, PhD, Professor of Radiation Oncology at MD Anderson. “Stereotactic radiation treatment is a relatively new approach for operable early-stage lung cancer, while surgery has been the standard for a century. This study can give physicians confidence to consider a noninvasive option.”
Study Findings
The researchers analyzed overall survival, recurrences, and toxicity in 58 patients. Estimated 3-year survival rates were 79% in the surgery group and 95% in the stereotactic ablative radiotherapy group, while recurrence-free survival rates at 3 years were 80% and 86%, respectively. Six patients in the surgery group died vs one death within the stereotactic ablative radiotherapy group. None of the patients treated with stereotactic ablative radiotherapy had high-grade toxicity.
The authors suggest that the lower survival rate following surgery could be attributed to other simultaneous conditions that were worsened by the surgical reduction of lung function. As such, the findings support stereotactic ablative radiotherapy as a noninvasive alternative, especially for elderly patients and for those with significant comorbidities.
“The findings of our study provide strong support for a large clinical trial to investigate the potential superiority of stereotactic ablative radiotherapy for patients with early-stage disease,” said senior author Jack A. Roth, MD, Professor and Bud Johnson Clinical Distinguished Chair Department of Thoracic & Cardiovascular Surgery at MD Anderson. “While we wait for more data, physicians can consider stereotactic ablative radiotherapy an effective treatment for these patients, especially for those whom surgery brings high risk.”
Possible Safe Alternative
Over the last decade, stereotactic ablative radiotherapy has been used to treat patients with inoperable NSCLC, showing outcomes that are better in some cases than traditional radiation. However, there has been no data on stereotactic ablative radiotherapy for patients with operable early-stage NSCLC because of concerns about the risk of recurrence after stereotactic ablative radiotherapy. Surgery, on the other hand—lobectomy with dissection of the lymph nodes—was thought to result in less chance for cancer to recur.
However, lung cancer surgery is a major operation with a high complication rate, and while recurrence rates are low, there is a 10% to 20% chance of the cancer coming back in the other lobes, regional lymph nodes, and distant organs, noted Dr. Chang. In this study there was no difference between stereotactic ablative radiotherapy and surgery for tumor recurrence.
He added that these findings should be interpreted with some caution, due to the small patient sample size and limited follow-up time. Two new randomized studies are in preparation and expected to be opened in 2015: VALOR in the United States, and, in the United Kingdom, SABRtooth, a multicenter pilot study of stereotactic ablative radiotherapy vs surgery in patients with peripheral stage I NSCLC considered at higher risk of complications from surgical resection.
Dr. Chang is the corresponding author for The Lancet Oncology article.
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