Surgery improved survival in early-stage lung cancer, but targeted radiotherapy may be as effective for patients aged 80 and over
Surgery should remain the primary treatment for people with early-stage non-small cell lung cancer (NSCLC) who are suitable for either surgery or a highly targeted form of radiotherapy, a new study from the London School of Hygiene & Tropical Medicine (LSHTM) suggests.
Published in the Journal of Clinical Oncology, the study compared surgery with stereotactic ablative radiotherapy (SABR), a highly targeted treatment that delivers high doses of radiation directly to a tumour, in NSCLC patients eligible for either treatment. Using national cancer data from 12,546 people diagnosed with early-stage NSCLC in England between 2015 and 2020, in a world-first researchers compared surgery and SABR using an emulated target trial which applies the principles of a randomised controlled trial to real-world data.
Among the study participants, 10,247 underwent surgery and 2,299 received SABR. After adjusting for differences between the groups, researchers estimated that 21.6% of people who underwent surgery died of any cause within three years, compared with 30.3% of those who had SABR, an average difference of 8.8 percentage points.
However, amongst people aged 80 and over, the research found no evidence of a clinically meaningful difference in three-year all-cause mortality between the two interventions. The findings suggest SABR could offer an alternative treatment with curative intent for selected older patients.
Eva Kagenaar, a Research Fellow at LSHTM and co-author of the study, said: "Using data from England's Cancer Registry, we found that surgery resulted in better survival than SABR for people with early-stage lung cancer. Our findings show how valuable patient records can be for guiding treatment decisions, particularly when clinical trials aren't able to answer critical questions quickly."
The research also reported average estimates of three-year lung cancer-specific mortality of 20.6% following SABR and 14.5% after surgery, and higher estimates of cancer recurrence following SABR versus surgery, but these differences were not statistically significant.
SABR is already recommended as a treatment with curative intent for people with early-stage NSCLC who are not medically fit for, or do not want to have surgery. In England, the researchers estimate that around 2,000 people diagnosed with early-stage lung cancer each year could be eligible for either SABR or surgery. Approximately one in five currently receive SABR, with its use increasing in recent years.
Richard Grieve, Professor of Health Economics at LSHTM and co-author of the study, said: "For most patients with early stage NSCLC who are eligible for surgery, our results provide reassurance that it remains the treatment most likely to improve survival rates. Our findings support current NICE guidance, while also helping to clarify where alternative treatments such as SABR, may improve patient outcomes and their quality of care."
Evidence comparing SABR and surgery for eligible patients with early-stage NSCLC remains limited, with previous trials failing to recruit enough participants and ongoing studies yet to report their datasets.
To help address this evidence gap, the researchers analysed data from England's National Cancer Registry linked with hospital and radiotherapy records. By using routinely collected NHS patient data, the study provides evidence that could help inform future treatment decisions and improve patient care.
The study was supported by the National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC): Manchester.
