Stereotactic ablative radiotherapy recommended for NSCLC patients at high risk for surgical complications

Gregory M. M. Videtic, MD, CM, FRCPC, MD, CM, FRCPC

For those who care for lung cancer patients, the paradigm change that stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) has brought about feels nothing short of miraculous. Patients with early stage disease, whose comorbidities or age previously would have made them ineligible for the only know curative therapy (surgical resection) now are offered remarkably effective and incredibly safe treatment, and accumulating evidence over the past 15 years has essentially established it as the standard of care for the medically inoperable patient.

Palma and colleagues draw on their published experience and that of others to discuss expanding the utility of SBRT to the potentially resectable but high-risk patient. Recognizing that the gold standard in treatment is the phase 3 trial, they use population-based studies and competing-risk data to suggest that SBRT/SABR as first-line treatment may be appropriately offered to the appropriately informed “high-risk” patient aware of both surgical and radiotherapy risks and benefits. For radiation oncologists with extensive SBRT experience, this indication has been felt to be valid for the fit but elderly (>75 years) population, and this review of the literature provides an excellent resource on which to draw when providing a treatment rationale. In summary, these authors have provided a clear and concise summary for clinicians wishing to decide on the parameters by which to select SBRT for their varied patient populations, as we await the results from formal clinical trials.

Sudha R. Amarnath, MD, MD

Lung cancer is the second most common cancer among men and women in the United States and the leading cause of cancer mortality. Early stage disease (stage IA/IB) represents approximately 15% of all newly diagnosed non–small cell lung cancers and historically has been considered the most curable stage of disease with surgical resection. Unfortunately, due to poor lung function and other comorbidities, many patients were unable to safely undergo surgery, leaving them without a curative option. Over the past 15 years, there has been accumulating evidence on the safety and efficacy of stereotactic ablative radiotherapy (SABR) in this patient population, and based on this evidence, SABR has become a standard tool for treating medically inoperable early stage lung cancers. Given the excellent local control as high as 98% in the most recent RTOG study and survival rates and low morbidity rates reported in these studies, experts in lung cancer now question whether SABR should be presented as a treatment option to medically operable patients with early stage lung cancers.

Given the lack of available phase 3 randomized data, Drs. Palma and Senan very nicely address this question with their review of population-based and competing risks data that show similar long-term outcomes (local control, survival) with either SABR or surgery, and decreased treatment-related mortality and 30-day mortality with SABR in “high-risk” patients, suggesting that SABR should at least be discussed and offered as a treatment option to this patient cohort.

As oncologists start to focus more on quality-of-life factors and shared decision-making, counseling patients on all available treatment options is of the utmost importance. This review provides the rationale for having medically operable “high-risk patients” see both a surgeon and radiation oncologist to discuss treatment options to make an informed decision. In the end, our patients will benefit by having all of the opinions on the table.