Lobectomy alternatives show varying adverse event profiles in early-stage lung cancer
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Although use of limited resection or stereotactic body radiation therapy for early-stage non-small cell lung cancer had comparable odds for at least one adverse event, the overall toxicity profiles differed, according to study results.
“We found that among unfit early-stage lung cancer patients who were not candidates for full anatomic lobar resection, those who underwent limited lung resection vs. stereotactic body radiation therapy (SBRT) in fact had similar risk of developing at least one adverse event at 3-month follow-up,” Qian Wang, MD, MPH, of University Hospitals Seidman Cancer Center, told Healio. “However, compared to limited resection, SBRT was associated with less risk of infectious (especially at 30 days post-treatment) and respiratory-related adverse events, but more patients treated with SBRT experienced fatigue up to 3 months.”
In a prospective observational study published in Annals of the American Thoracic Society, Wang and colleagues analyzed 252 patients with stage I to IIA non-small cell lung cancer not suitable for lobectomy to compare adverse events that resulted from limited resection and SBRT 30 and 90 days after treatment. Patients included in this study had no lymph node involvement, tumors 5 cm or smaller and came from five institutions in the U.S. from September 2016 to May 2021.
“Due to coexisting comorbidities, poor lung function, limited functional status and frailty, approximately 25% of early-stage lung cancer patients are not medically fit for standard-of-care full anatomic lobar resection (ie, lobectomy),” Wang told Healio. “For them, limited resection (such as segmentectomy or wedge resection) and SBRT are alternative treatment options. However, there is currently no data available from well-powered randomized controlled trials comparing the oncologic outcomes of SBRT vs. surgery. Treatment-related adverse events are important patient centered outcomes that may be highly relevant in the case of possible oncological equipoise.”
Researchers evaluated adverse events — which fell into one of 10 categories based on the impacted organ system: constitutional, cardiovascular, respiratory, gastrointestinal, musculoskeletal, cutaneous, infectious, hematological, neurological and other — using propensity scores and inverse probability weighting.
Of the total cohort, 88 patients (35%; mean age, 69.7 years; 56.8% women; 64.8% white) underwent limited resection and 164 patients (65%; mean age, 74.3 years; 50% women; 86% white) received SBRT.
In terms of experiencing at least one adverse event, researchers found no significant differences between SBRT and limited resection at 30 days (OR = 1; 95% CI, 0.65-1.55) and 90 days (OR = 1.27; 85% CI, 0.84-1.91) based on propensity scored-adjusted analyses.
After treatment, patients who received SBRT had a smaller risk for experiencing infectious adverse events, such as urinary tract infections, compared with patients who received limited resection (30-day OR = 0.05; 95% CI, 0.01-0.39; 90-day OR = 0.41; 95% CI, 0.17-0.98).
In addition, researchers observed that SBRT lowered risk for respiratory adverse events — such as dyspnea, bronchospasm and pleural effusion — at both 30 days (OR = 0.36; 95% CI, 0.2-0.65) and 90 days (OR = 0.51; 95% CI, 95% CI, 0.31-0.86); however, these patients also had higher risk for fatigue (30-day OR = 2.47; 95% CI, 1.34-4.54; 90-day OR = 2.69; 95% CI, 1.52-4.77).
“For patients who are at high risk of developing post-operative infection, for example, having uncontrolled diabetes, existing chronic infections or are immunodeficient due to other causes, SBRT may be a safer approach than limited resection to mitigate the risk of post-operative infections such as pneumonia, unhealing wound or urinary tract infection,” Wang said. “However, patients should be informed that SBRT may potentially lead to a higher risk of fatigue that could last up to 3 months. Though most fatigue was mild, providers should screen fatigue and rule out other causes.”
Researchers noted no differences between both treatments and their risk for cardiovascular or musculoskeletal (chest wall and rib pain) unfavorable events at 90 days in adjusted analyses. The adjusted risk of neurological, cutaneous, gastrointestinal and hematological adverse events could not be compared between two treatment arms due to low rates of these events.
“Our results could provide practical knowledge for providers to directly inform patient-centered cancer care,” Wang told Healio. “Oncological providers should inform patients that patients are at equal risk of developing at least one adverse event when treated with SBRT or limited resection; however, they may have different adverse event profiles.”
Wang continued that most events are nonsevere and their risk is related to tumor location, treatment and radiotherapy dose, patients’ underlying comorbidities and baseline risk factors.
“In the future, the long-term adverse events associated with SBRT vs. limited resection and the clinical efficacy including local recurrence rate, metastatic recurrence rate, disease-specific survival and overall survival need to be assessed,” Wang added.
This study by Wang and colleagues adds to the literature indicating that questions still remain for which alternative treatment is the best option, according to an accompanying editorial by Joseph D. Phillips, MD, assistant professor of thoracic surgery at Dartmouth-Hitchcock Medical Center.
“Clearly, the debate for optimal treatment for high-risk patients undergoing lobectomy will continue,” Phillips wrote. “The involvement of a multidisciplinary team in deciding the most appropriate, individualized care for these patients is paramount. Local resources, provider expertise and patient preference regarding possible treatments must all be heavily weighed when deciding on a treatment plan. This study adds important, generalizable, real-world data to the armamentarium for helping patients decide which treatment may be best for them.”
For more information:
Qian Wang, MD, MPH, can be reached at qian.wang@uhhospitals.org.