Surgery versus SABR for resectable non-small-cell lung cancer - Part 6 of 9

This is a letter in response to the article by Chang and colleagues. The authors warn to interpret the findings of the original article, that SABR is better tolerated and might lead to improved survival compared to surgery for good risk patients with clinical stage I NSCLC, with caution. They highlight two pitfalls of the original study. First, the comparison was between up to date SABR technology and outdated surgical techniques (primarily thoracotomy). They cite that thoracotomy should not be considered surgical standard of care for patients with early stage NSCLC as VATS is associated with lower morbidty and mortality without compromising outcomes from a cancer standpoint. According to large national databases, procedure-related mortality from SABR (0.7%) and VATS lobectomy (0.8%) are similar. Second, they highlight the methodological limitations of this study. Given the small sample size and short follow-up, they point out that the survival outcomes are inaccurate. The rate of locoregional recurrence was 16.1% in the SABR arm and 4.1% in the surgical arm, but it is unclear how this would affect cancer-specific survival as the study was not designed to properly answer that question. In addition, biopsy proof of NSCLC was not required in the ROSEL trial and therefore it is unknown how many patient in the SABR arm truly had NSCLC, whereas one patient in the surgical arm had benign disease.  They conclude that randomized controlled trials (RCTs) comparing best therapy in each arm are needed.