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Great debate: surgery versus stereotactic radiotherapy for early-stage non-small cell lung cancer
  1. Crispin Hiley1,2,
  2. Ahmed Salem1,3,
  3. Tim Batchelor4,
  4. Fiona McDonald5,
  5. Matthew Evison6,7
  1. 1 CRUK Lung Cancer Centre of Excellence, University College London & The University of Manchester, London & Manchester, UK
  2. 2 Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
  3. 3 Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
  4. 4 Thoracic Surgery, Bristol Royal Infirmary, Bristol, UK
  5. 5 Clinical Oncology, Royal Marsden NHS Foundation Trust, London, UK
  6. 6 North West Lung Centre, University Hospital South Manchester, Manchester, UK
  7. 7 Institute of Inflammation and Repair, University of Manchester, Manchester, UK
  1. Correspondence to Dr Crispin Hiley, CRUK Lung Cancer Centre of Excellence, University College London, London WC1E 6BT, UK; Crispin.Hiley{at}crick.ac.uk

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Stereotactic ablative radiotherapy (SABR) for primary early-stage non-small cell lung cancer (NSCLC) is a precision therapy given over three to eight fractions, delivering a high dose to the tumour while minimising the dose to surrounding non-malignant tissues. SABR offers several advantages over conventionally fractionated radiotherapy, which is given daily for 4.0–6.5 weeks. Importantly, due to improved radiotherapy conformality, SABR allows a higher biologically effective dose (BED) to be given compared with conventionally fractionated radiotherapy. The increased tumour control using a higher BED was demonstrated recently in the phase III randomised CHISEL trial, which reported significantly reduced local failure rates in patients with peripheral tumours treated with SABR compared with conventionally fractionated radiotherapy (14% vs 31%) and an improvement in overall survival (OS).1 This is reflected in real-world data from the UK National Lung Cancer Audit (NLCA), which showed that the HR for death for those who underwent SABR was 0.69 compared with conventionally fractionated radiotherapy.2

The current National Institute for Clinical Excellence guidelines recommend that SABR should only be offered to patients who decline or are not suitable or considered at high risk for surgery with lobectomy. While patient preference for surgery or SABR does exist,3 UK patients undergoing SABR are predominantly those felt to be unsuitable for surgery due to frailty and/or the presence of comorbidities. Despite the success of comparing SABR with conventionally fractionated radiotherapy, attempts to objectively compare SABR with surgery have failed with the early closure of several international (STARS and ROSEL) and a UK randomised trial (SABRTOOTH) due to poor recruitment. Other trials comparing surgery and SABR in operable patients with stage I NSCLC are ongoing (NCT02468024, STABLE-MATES, and NCT02984761, VALOR).

In the absence of high-quality data, clinical guidelines are forced to make recommendations based on lower levels of evidence. …

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Footnotes

  • Twitter @matthewevison1

  • Contributors All authors contributed equally to this manuscript.

  • Funding This study was funded by UCLH Biomedical Research Centre.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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