Comparative effectiveness of stereotactic body radiation therapy versus surgery for stage I lung cancer in otherwise healthy patients: An instrumental variable analysisCentral MessagePerspective
Michael J. Littau, BA,
Richard Freeman, MD, MBA,
Wickii T. Vigneswaran, MD, MBA,
Fred A. Luchette, MD, MSc,
Marshall S. Baker, MD, MBA,
Wissam Raad, MD,
Zaid M. Abdelsattar, MD, MSc,
Tyler Grenda, MD, MS,
James Lubawski, MD,
Maria Lucia L. Madariaga, MD
Affiliations
Michael J. Littau, BA
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill
Richard Freeman, MD, MBA
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Department of Cardiovascular and Thoracic Surgery, Loyola University Medical Center, Maywood, Ill
Wickii T. Vigneswaran, MD, MBA
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Department of Cardiovascular and Thoracic Surgery, Loyola University Medical Center, Maywood, Ill; Edward Hines Jr., Veterans Administration Medical Center, Hines, Ill
Fred A. Luchette, MD, MSc
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Edward Hines Jr., Veterans Administration Medical Center, Hines, Ill
Marshall S. Baker, MD, MBA
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Edward Hines Jr., Veterans Administration Medical Center, Hines, Ill
Wissam Raad, MD
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Department of Cardiovascular and Thoracic Surgery, Loyola University Medical Center, Maywood, Ill
Zaid M. Abdelsattar, MD, MSc
Stritch School of Medicine, Loyola University Chicago, Maywood, Ill; Department of Cardiovascular and Thoracic Surgery, Loyola University Medical Center, Maywood, Ill; Edward Hines Jr., Veterans Administration Medical Center, Hines, Ill; Address for reprints: Zaid M. Abdelsattar, MD, MSc, Department of Thoracic Surgery, Loyola University Medical Center, 2160 S. First Ave, Bldg. 110, Room 6260, Maywood, IL 60153.
Objectives: Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database. Methods: We identified all patient with clinical stage I non–small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument. Results: Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable–adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P < .001). Both lobectomy (hazard ratio, 0.17) and sublobar resections (hazard ratio, 0.28) were associated with improved overall survival compared with SBRT (P < .001). Conclusions: In otherwise healthy patients with stage I NSCLC, surgical resection is associated with a survival benefit compared with SBRT. This is true for both lobar and sublobar resections.
