To SABR or Not to SABR? Indications and Contraindications for Stereotactic Ablative Radiotherapy in the Treatment of Early-Stage, Oligometastatic, or Oligoprogressive Non–Small Cell Lung Cancer
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Abstract
Stereotactic ablative radiotherapy (SABR) is a highly effective treatment for early-stage
non-small cell lung cancer. Although direct comparisons from randomized trials are
not available, rates of both primary tumor control and distant metastasis are similar
between SABR and surgery. Overall survival is lower after SABR compared with surgery,
largely reflecting that a primary selection criterion for SABR has been medical inoperability
because of decreased cardiopulmonary function and other comorbidities that lead to
decreased survival independent of non-small cell lung cancer. Survival outcomes between
SABR and surgery are much more similar in propensity-matched cohorts. Newer potential
indications for SABR include treatment of operable patients; of oligometastatic lung
cancer, in which SABR has emerged as an alternative to metastasectomy; and of oligoprogressive
lung cancer, an attractive concept especially as improved personalized systemic therapies
emerge, and prospective trials are currently being conducted in these settings. Although
toxicity in modern series is low, SABR is clearly capable of producing fatal complications,
and understanding the risk factors and approaches for mitigating them has been emerging
in recent years. Thus, appropriate patient selection is a vital, evolving, and controversial
topic.