Surgery or Radiation for Early Staged, Operable Lung Cancer: Which Road Should I Take?

By guest host Mara B. Antonoff, MD, and host David Tom Cooke, MD

As a newly established group in the world of health care social media, the Thoracic Surgery Social Media Network (#TSSMN, @tssmn) is thrilled for the opportunity to cohost our first Tweet chat with #LCSM Chat. We are delighted at this collaboration, bringing together a number of key stakeholders in lung cancer and thoracic surgery, for an important discussion regarding the roles of surgical resection and stereotactic body radiotherapy (SBRT; also known as stereotactic ablative radiotherapy or SABR) for early staged lung cancer. We cannot think of a better way to kick off our first live chat, and we hope that you will join us.

TSSMN was established in July, 2015, as a collaborative effort by the leading journals in the field of Thoracic Surgery, The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery. The goals of this initiative were to bring social media attention to key publications from both of the journals and to highlight some of the amazing accomplishments in our specialty. Key leaders in thoracic surgery and innovators in social media were selected as delegates for this joint project. On a monthly basis, members from the TSSMN provide tweets related to key articles from each of our top journals within the realms of Adult Cardiac, Pediatric Cardiovascular, and General Thoracic Surgery, with the tag #tssmn. In addition, members of the TSSMN will host live 1-hour tweetchats 3 times per year, addressing hot topics from both journals in a timely fashion.  For the General Thoracic subgroup, we are excited to partner on our inaugural chat with #LCSM Chat.

The topic that we have chosen for our first chat is both timely and debate provoking, and we are eager to see the exciting exchanges that will take place among patients, care providers and physicians, researchers and advocates, surgeons and radiation oncologists. In June, 2015, an article was published in The Lancet Oncology (Chang et al), combining patient groups from both two clinical trials (the STARS and ROSEL trials), concluding that SBRT may be a first line option for treating operable stage I non-small cell lung cancer (NSCLC) in physically fit patients. STARS and ROSEL were two independent, randomized, trials of SBRT in patients with operable stage I NSCLC. Both of these original trials closed early due to slow accrual, and the publication of this recent article has led to much discussion, as the authors drew the conclusions: SBRT was equivalent to surgery in cancer specific survival after 3 years.

Criticisms of the trial include the design of the trial, inability to enroll interested patients and the fact there were only about 30 patients in each experimental arm. A response to that trial published in the Journal of Thoracic and Cardiovascular Surgery (JTCVS) by Meyers BF et al noted that the Lancet Oncology analysis was a “pooled analysis of the failed STARS and ROSEL trials [was] underpowered, producing a randomized but unstable and invalid comparison between SBRT and surgery.”

Also in the JTCVS, Dr. Crabtree et al reviewed the Washington University in St. Louis’ experience with surgery versus SBRT for stage I lung cancer and found that surgery demonstrated a 3-year cancer specific survival of 72%, and for patients treated with SBRT the treatment resulted in a 3-year cancer specific survival of 42%. In addition the overall local recurrence rate (cancer coming back in the same site) for surgery was 2.6%. The overall local recurrence rate for SBRT was 10.7%.

A recent study published in the Annals of Thoracic Surgery by Dr. Port et al from Cornell compared patients undergoing wedge surgery versus SBRT for stage I lung cancer at their institution, and found that overall recurrence (local and distant) was significantly higher after SBRT (wedge, 9%; SBRT, 30%), though there was no difference between the two groups in cancer specific 3-year survival.

What’s the right answer for the treatment of early stage lung cancer? Is there a right answer?

Guiding our discussion will be the following questions:

1. What are the limitations to the knowledge that we currently have available comparing surgery and SBRT for early lung cancer?
2. What factors should patients & families consider when debating between surgical resection and SBRT for early Lung Cancer?
3. What info would patients and their families want to help better make a decision between the two treatments?
4. How can we improve clinical trial enrollment to better compare surgery & SBRT?

WE KNOW THE ABOVE REFERENCED ARTICLES ARE NOT OPEN ACCESS! We understand the frustration and are working on it. Our hope is that for future TSSMN chats, relevant articles will be released for open access. Until then the abstracts are readily available.

Please join us on Thursday, September 17th, 8pm ET, 5pm PT, to discuss this important topic. Remember to add the hashtags #LCSM and #TSSMN to your tweets at the appointed hour and follow the tweet stream. If you’re not familiar with tweet chats, here is information on how to participate in #LCSM Chat.