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Comparison of the Efficacy of Stereotactic Body Radiotherapy versus Surgical Treatment for Early-Stage Non-Small Cell Lung Cancer after Propensity Score Matching
* School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou 215123, China;
†Department of Radiation Oncology, Zhejiang Key Lab of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou 310011, China; ‡Department of Thoracic Oncology Surgery, Zhejiang Key Lab of Thoracic Oncology Surgery, Zhejiang Cancer Hospital l, Hangzhou 310011, China
Background: The objective of this study was to evaluate the clinical efficacy of stereotactic body radiotherapy (SBRT) and surgical treatment for stage I–II non-small cell lung cancer (NSCLC). Methods: This retrospective analysis included 879 patients with primary NSCLC who underwent SBRT or surgical treatment in Zhejiang Cancer Hospital, Hangzhou, China from January 2012 to December 2017. Results: Propensity score matching (PSM) analysis was performed between the two groups. Each group included 66 patients who met the inclusion criteria. The median follow-up in the SBRT and surgery groups was 30.8 and 48.4 months, respectively. In the SBRT group, the 1- and 3-year overall survival rates were 98.5 and 83.9%, respectively. In the surgery group, these rates were 98.5 and 89.4%, respectively (P = .248). The 3-year cancer-specific survival rates in the SBRT and surgery groups were 89.1 and 95.2%, respectively (P = .056). Conclusions: In these propensity score matched early-stage NSCLC patients, the 1- and 3-year overall survival rates associated with SBRT were similar to those observed with surgery. In addition, there was no significant difference in cancer-specific survival between the two groups.
Surgical anatomic resection with MF498 node evaluation remains the standard of care for operable patients with early-stage non-small cell lung cancer [1,2]. However, 20% to 30% of patients are inoperable due to advanced age or the presence of comorbidities [3,4]. Stereotactic body radiotherapy delivers high radiation doses to restricted volumes through multiple precisely aimed radiother-apy beams [5,6]. This approach is currently considered as the preferred treatment option in patients unfit for surgery or at high risk for the occurrence of postoperative complications . One of the potential indications of SBRT is operable patients. Several retrospective studies and prospective trials have shown that overall survival (OS) after SBRT was comparable with that reported after surgical resection [8–12]. However, a retrospective series showed that there are important differences between patients treated with surgery and those who received SBRT in terms of age, performance status, comorbid medical conditions, etc. These differences render direct comparisons between these two ap-proaches problematic. Moreover, thus far, there are no phase III
prospective randomized trials comparing the two treatment modalities have completed.
Propensity score matching analysis allows for matching across a broad range of baseline factors, producing two similar groups for comparison [13,14]. In this study, we performed a comprehensive PSM analysis designed to compare the outcomes of two potentially curative approaches for stage I–II NSCLC using uniform definitions of recurrence and survival from recently completed and ongoing clinical trials. We hypothesized that locoregional control (LRC) and cancer-specific survival (CSS) in r> early-stage NSCLC patients undergoing surgery or SBRT may be comparable.
Materials and Methods
Patients with cytologically/histologically or clinically confirmed NSCLC from January 2012 to December 2017 were eligible for inclusion in the study. They were staged according to the findings of chest computed tomography (CT). Patients with radiologically suspicious lymph nodes underwent endobronchial ultrasonography or mediastinoscopy. In addition, patients underwent bone imaging and brain magnetic resonance imaging or fludeoxyglucose-positron-emission tomography (18FDG-PET) to identify the presence of T1–2 N0 M0. Disease staging was performed using the Unite and Support the Cancer Community (UICC) TNM-7th edition. The indications were fully examined and discussed among patients, surgeons, radiation oncologists, and diagnostic radiologists. All multidisciplin-ary consultations were recorded in detail. Patients with adequate pulmonary function to tolerate at least a lobectomy and absence of other contraindicating medical comorbidity—according to the thoracic surgeon—were selected for lobar resection. Radical lymph node dissection was performed in accordance with the current guidelines . Inoperable patients—according to the thoracic surgeon—and those who refused sublobar resection were selected for SBRT. Target coverage, conformality, and normal tissue constraints were investigated according to the protocol for the clinical trial Radiotherapy Oncology Group (RTOG) 0236 . Treatment plans were optimized to limit the administration of high doses to regions of organs at risk. This was achieved using more fractions and a lower dose per fraction for larger tumors and those adjacent to critical organs . Biological effective dose (BED) was calculated using BEDα/β = nd(1+ d/α/β), where n = number of fractions, d = dose per fraction, and α/β = 10 for the tumor in line with prior reports . Patients received a median BED10 of 100 Gy (range: 71–120 Gy). Exclusion criteria included patients with Karnofsky Performance Status ≤60; other antitumor therapy within 3 months prior to surgery or SBRT; local recurrence and distant metastasis within 3 months after surgery or SBRT; and lost to follow-up.