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The paper by Dowie and Wildman1 exploring the decision analysis for surgically high risk patients with stage Ia non-small cell lung cancer (NSCLC) was interesting. However, I have reservations about the figures used to inform the decision tree.
There has never been a randomised trial comparing surgery with radical radiotherapy for these patients and the authors have taken 5 year survival figures for quite different groups of patients. The surgical survival figures come from a very large series of patients of all ages and levels of fitness,2 while the radical radiotherapy figures come from one relatively small retrospective series of patients who were considered unfit for (or refused) surgery.3 These patients have, for reasons of age and co-morbidity, a lower background probability of 5 year survival. The Cochrane Review on this topic4 identified 26 studies, including over 2000 patients. For patients with T1 tumours from six studies, 5 year survival ranged from 29% to 37%, but there was a high rate of intercurrent deaths (median 25%). …