- Email: [email protected]
Surgery versus SABR for NSCLC
Correspondence
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Van Schil PE, Van Meerbeeck J. Surgery or radiotherapy for early-stage lung cancer—a potential comparison bias. Lancet Oncol 2013; 14: e390. Senan S, Paul MA, Lagerwaard FJ. Treatment of early-stage lung cancer detected by screening: surgery or stereotactic ablative radiotherapy? Lancet Oncol 2013; 14: e270–74. Lagerwaard FJ, Verstegen NE, Haasbeek CJ, et al. Outcomes of stereotactic ablative radiotherapy in patients with potentially operable stage I non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2012; 83: 348–53. Onishi H, Shirato H, Nagata Y, et al. Stereotactic body radiotherapy (SBRT) for operable stage I non-small-cell lung cancer: can SBRT be comparable to surgery? Int J Radiat Oncol Biol Phys 2011; 81: 1352–58. Corradetti MN, Haas AR, Rengan R. Central-airway necrosis after stereotactic body-radiation therapy. N Engl J Med 2012; 366: 2327–29. Senthi S, Haasbeek CJ, Slotman BJ, Senan S. Outcomes of stereotactic ablative radiotherapy for central lung tumours: a systematic review. Radiother Oncol 2013; 106: 276–82. Zumsteg ZS, Zelefsky MJ. Improved survival with surgery in prostate cancer patients without medical comorbidity: a self-fulfilling prophecy? Eur Urol 2013; 64: 381–83. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991; 324: 1685–90. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365: 395–409.
Paul Van Schil and Jan Van Meerbeeck outline the challenges in comparing outcomes between surgery and stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer (NSCLC).1 They argue that such comparisons are flawed, mainly because of different definitions of recurrence, and heterogeneity in the quality of SABR across different centres. The authors conclude that in the absence of a randomised trial, surgery must remain the standard of care. The American College of Chest Physicians and the Society of Thoracic Surgeons recently suggested a common terminology describing tumour recurrence for early NSCLC that substantially reduces the potential for bias due to differing outcome definitions. In e491
fact, published works have already used recurrence definitions that allow for more equal comparisons between surgery and SABR. In a propensity score-matched analysis, locoregional control was defined as the absence of a recurrence adjacent to the surgical margin or planning target volume, or in the ipsilateral hilum or mediastinum. Locoregional control after stereotactic ablative radiotherapy was superior to that after lobectomy, with no significant differences in distant recurrence or survival.2 Quality assurance is a key component of stereotactic ablative radiotherapy, as it is with surgery. Multi-institutional trials and systematic reviews suggest that outcomes with SABR are generally consistent across several centres.3 By contrast, results of hospital-volume studies suggest that surgical mortality data do not generalise well to smaller centres.4 We agree that the absence of randomised trials is not ideal; however, this is not due to a lack of international effort. The absence of randomised data does not imply the absence of evidence, and we must rely on other forms of comparative effectiveness research to inform clinical practice. In addition to singleinstitutional and multi-institutional propensity-matched studies suggesting similar outcomes with SABR and surgery, assessment of populationbased data has suggested similar conclusions.5 A propensity-matched population-based analysis using the SEER-Medicare database suggests that short-term mortality is improved with SABR (<1%) compared with either lobectomy or sublobar resection (about 4%), and long-term survival did not differ. When randomised trials do not provide definitive comparisons, surgery and radiotherapy can both be regarded as gold-standard treatments based on other levels of evidence, as is the case in early stage prostate cancer.6
The choice between SABR and surgery should be made for each individual on the basis of the relative merits and drawbacks of each modality. Despite the promising results of radiotherapy, outcomes after lobectomy have longer-term follow-up and should not be ignored. Conversely, the high surgical mortality rate in some patients is of particular importance for decision-making for individuals who are risk-averse to the possibility of treatment-related death. Multidisciplinary management, with thorough discussion of the advantages and disadvantages of each treatment option, should be the gold-standard treatment approach for early-stage NSCLC. We declare that we have no conflicts of interest.
Alexander V Louie, Sasha Senthi, *David A Palma [email protected] London Regional Cancer Program, London, ON, Canada (AVL); William Buckland Radiotherapy Centre, Alfred Heath, Melbourne, VIC, Australia (SS); and London Regional Cancer Program, London, ON, Canada (DAP) 1
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Van Schil PE, Van Meerbeeck J. Surgery or radiotherapy for early-stage lung cancer—a potential comparison bias. Lancet Oncol 2013; 14: e390. Verstegen NE, Oosterhuis JW, Palma DA, et al. Stage I–II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis. Ann Oncol 2013; 24: 1543–48. Guckenberger M, Allgäuer M, Appold S, et al. Safety and efficacy of stereotactic body radiotherapy for stage I non-small-cell lung cancer in routine clinical practice: a patterns-of-care and outcome analysis. J Thorac Oncol 2013; 8: 1050–58. LaPar DJ, Bhamidipati CM, Lau CL, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: establishing generalizability to national lung cancer resection outcomes. Ann Thorac Surg 2012; 94: 216–21. Shirvani SM, Chang JY, Roth JA. Can stereotactic ablative radiotherapy in early stage lung cancers produce comparable success as surgery? Thorac Surg Clin 2013; 23: 369–81. Mohler J, Bahnson RR, Boston B, et al. NCCN clinical practice guidelines in oncology: prostate cancer. J Natl Compr Canc Netw 2010; 8: 162–200.
www.thelancet.com/oncology Vol 14 November 2013
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Van Schil PE, Van Meerbeeck J. Surgery or radiotherapy for early-stage lung cancer—a potential comparison bias. Lancet Oncol 2013; 14: e390. Senan S, Paul MA, Lagerwaard FJ. Treatment of early-stage lung cancer detected by screening: surgery or stereotactic ablative radiotherapy? Lancet Oncol 2013; 14: e270–74. Lagerwaard FJ, Verstegen NE, Haasbeek CJ, et al. Outcomes of stereotactic ablative radiotherapy in patients with potentially operable stage I non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2012; 83: 348–53. Onishi H, Shirato H, Nagata Y, et al. Stereotactic body radiotherapy (SBRT) for operable stage I non-small-cell lung cancer: can SBRT be comparable to surgery? Int J Radiat Oncol Biol Phys 2011; 81: 1352–58. Corradetti MN, Haas AR, Rengan R. Central-airway necrosis after stereotactic body-radiation therapy. N Engl J Med 2012; 366: 2327–29. Senthi S, Haasbeek CJ, Slotman BJ, Senan S. Outcomes of stereotactic ablative radiotherapy for central lung tumours: a systematic review. Radiother Oncol 2013; 106: 276–82. Zumsteg ZS, Zelefsky MJ. Improved survival with surgery in prostate cancer patients without medical comorbidity: a self-fulfilling prophecy? Eur Urol 2013; 64: 381–83. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991; 324: 1685–90. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365: 395–409.
Paul Van Schil and Jan Van Meerbeeck outline the challenges in comparing outcomes between surgery and stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer (NSCLC).1 They argue that such comparisons are flawed, mainly because of different definitions of recurrence, and heterogeneity in the quality of SABR across different centres. The authors conclude that in the absence of a randomised trial, surgery must remain the standard of care. The American College of Chest Physicians and the Society of Thoracic Surgeons recently suggested a common terminology describing tumour recurrence for early NSCLC that substantially reduces the potential for bias due to differing outcome definitions. In e491
fact, published works have already used recurrence definitions that allow for more equal comparisons between surgery and SABR. In a propensity score-matched analysis, locoregional control was defined as the absence of a recurrence adjacent to the surgical margin or planning target volume, or in the ipsilateral hilum or mediastinum. Locoregional control after stereotactic ablative radiotherapy was superior to that after lobectomy, with no significant differences in distant recurrence or survival.2 Quality assurance is a key component of stereotactic ablative radiotherapy, as it is with surgery. Multi-institutional trials and systematic reviews suggest that outcomes with SABR are generally consistent across several centres.3 By contrast, results of hospital-volume studies suggest that surgical mortality data do not generalise well to smaller centres.4 We agree that the absence of randomised trials is not ideal; however, this is not due to a lack of international effort. The absence of randomised data does not imply the absence of evidence, and we must rely on other forms of comparative effectiveness research to inform clinical practice. In addition to singleinstitutional and multi-institutional propensity-matched studies suggesting similar outcomes with SABR and surgery, assessment of populationbased data has suggested similar conclusions.5 A propensity-matched population-based analysis using the SEER-Medicare database suggests that short-term mortality is improved with SABR (<1%) compared with either lobectomy or sublobar resection (about 4%), and long-term survival did not differ. When randomised trials do not provide definitive comparisons, surgery and radiotherapy can both be regarded as gold-standard treatments based on other levels of evidence, as is the case in early stage prostate cancer.6
The choice between SABR and surgery should be made for each individual on the basis of the relative merits and drawbacks of each modality. Despite the promising results of radiotherapy, outcomes after lobectomy have longer-term follow-up and should not be ignored. Conversely, the high surgical mortality rate in some patients is of particular importance for decision-making for individuals who are risk-averse to the possibility of treatment-related death. Multidisciplinary management, with thorough discussion of the advantages and disadvantages of each treatment option, should be the gold-standard treatment approach for early-stage NSCLC. We declare that we have no conflicts of interest.
Alexander V Louie, Sasha Senthi, *David A Palma [email protected] London Regional Cancer Program, London, ON, Canada (AVL); William Buckland Radiotherapy Centre, Alfred Heath, Melbourne, VIC, Australia (SS); and London Regional Cancer Program, London, ON, Canada (DAP) 1
2
3
4
5
6
Van Schil PE, Van Meerbeeck J. Surgery or radiotherapy for early-stage lung cancer—a potential comparison bias. Lancet Oncol 2013; 14: e390. Verstegen NE, Oosterhuis JW, Palma DA, et al. Stage I–II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis. Ann Oncol 2013; 24: 1543–48. Guckenberger M, Allgäuer M, Appold S, et al. Safety and efficacy of stereotactic body radiotherapy for stage I non-small-cell lung cancer in routine clinical practice: a patterns-of-care and outcome analysis. J Thorac Oncol 2013; 8: 1050–58. LaPar DJ, Bhamidipati CM, Lau CL, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: establishing generalizability to national lung cancer resection outcomes. Ann Thorac Surg 2012; 94: 216–21. Shirvani SM, Chang JY, Roth JA. Can stereotactic ablative radiotherapy in early stage lung cancers produce comparable success as surgery? Thorac Surg Clin 2013; 23: 369–81. Mohler J, Bahnson RR, Boston B, et al. NCCN clinical practice guidelines in oncology: prostate cancer. J Natl Compr Canc Netw 2010; 8: 162–200.
www.thelancet.com/oncology Vol 14 November 2013