Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with stage I non-small-cell lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with Stage I non-small cell lung cancer?'. Altogether over 318 papers were found, of which 18 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Stereotactic ablative radiotherapy (SABR) and sublobar resection (SLR) offer clear survival benefit in the treatment of early-stage non-small-cell lung cancer (NSCLC) in high-risk patients unsuitable for lobectomy and SABR has shown good results in medically operable patients. No randomized data are available comparing SLR and SABR, and therefore, data from prospective studies were compared. Overall survival at 1 year was similar between patients treated with SABR and SLR (81-85.7 vs 92%); however, overall 3-year survival was higher following SLR (87.1 vs 45.1-57.1%). There was no statistically significant difference in local recurrence in patients treated with SABR compared with SLR (3.5-14.5 vs 4.8-20%). Both treatment modalities are associated with complications. Fatigue (31-32.6%), pneumonitis (2.1-12.5%) and chest wall pain (3.1-12%) were common following SABR; however, serious grade 3 and 4 toxicity were rare. Morbidity following SLR was reported between 7.3 and 33.7%. Thirty-day mortality following SABR was 0%, while predicted 30-day mortality following a lung resection, using the thoracoscore predictive model ranges between 1 and 2.6%. Treatment for early-stage NSCLC should be tailored to individual patients. SABR is an acceptable alternative to SLR in high-risk patients but comparative data are required.