Comparison of Long-term Survival of Patients With Early-Stage Non–Small Cell Lung Cancer After Surgery vs Stereotactic Body Radiotherapy

Key Points

Question

How does the long-term survival after curative-intent surgery with regional lymph node examination of various extents compare with long-term survival after stereotactic body radiotherapy for early-stage non–small cell lung cancer?

Findings

In this cohort study of 104 709 patients in the US National Cancer Database with early-stage non–small cell lung cancer, those who received surgery coupled with regional lymph node examination of an appropriate extent had significantly better long-term survival than those who received stereotactic body radiotherapy.

Meaning

These findings suggest that curative-intent surgery, when coupled with regional lymph node examination, is generally associated with the best long-term overall survival in patients with early-stage non–small cell lung cancer.

Abstract

This cohort study compares long-term overall survival of patients with early-stage non–small cell lung cancer treated with stereotactic body radiotherapy vs surgery including various degrees of lymph node examination.

Abstract

Importance

Previous comparisons of surgery and stereotactic body radiotherapy (SBRT) for early-stage (ES) non–small cell lung cancer (NSCLC) did not account for the extent of regional lymph node examination (LNE) during surgery.

Objective

To compare long-term overall survival (OS) of patients with ES NSCLC after surgery vs SBRT when the extent of regional LNE in patients undergoing surgery is thoroughly considered.

Design, Setting, and Participants

Cohort study with survival comparisons using the multivariable Cox proportional hazards model and after propensity score matching. Data from the National Cancer Database were analyzed from October 28, 2018, through April 18, 2019. Patients with ES NSCLC diagnosed between January 1, 2004, and December 31, 2015, who underwent any curative-intent surgery or SBRT were included.

Main Outcomes and Measures

Long-term OS.

Results

Of 104 709 total patients, 91 330 underwent surgery (42 508 [46.5%] male; median [interquartile range] age, 68 [61-75] years) and 13 379 received SBRT (6065 [45.3%] male; median [interquartile range] age, 75 [68-81] years). Surgery, especially lobectomy (hazard ratio [HR], 0.53; 95% CI, 0.50-0.56), and regional LNE, especially when more than 10 lymph nodes were examined (HR, 0.73; 95% CI, 0.69-0.77), were associated with better long-term OS ( P < .001). Pneumonectomy was not associated with reduced mortality risk when 0 nodes were examined (HR for stage T1, 1.43; 95% CI, 0.67-3.06; P = .35; HR for stage T2-T3, 0.62; 95% CI, 0.34-1.13; P = .12) or when more than 15 nodes were examined for stage T1 disease in patients younger than 80 years (HR, 0.77; 95% CI, 0.54-1.09; P = .14) or when patients aged 80 years or older received regional LNE of any extent (>15 nodes examined: HR for stage T1, 0.65; 95% CI, 0.16-2.64; P = .54; HR for stage T2-T3, 0.90; 95% CI, 0.50-1.60; P = .71). Less extensive surgery was not associated with improved OS when 0 nodes were examined in patients aged 80 years or older with stage T2 to T3 tumors (HR for lobectomy, 0.90; 95% CI, 0.65-1.25; P = .53) and in selected operable patients older than 75 years with stage T1 tumors (HR for lobectomy, 1.07; 95% CI, 0.57-2.00; P = .84).

Conclusions and Relevance

This study found that, overall, surgery coupled with regional LNE of appropriate extent was associated with the best long-term OS in patients with ES NSCLC.