Current evidence and ongoing trials for surgery versus stereotactic body radiation therapy (SBRT) for early-stage non-small cell lung cancer: a narrative review.

Background and Objective: Pulmonary resection with mediastinal lymph node dissection is the standard of care for standard-risk operable patients with early-stage non-small cell lung cancer (NSCLC), while stereotactic body radiation therapy (SBRT) is the mainstay treatment for inoperable patients. Within the last decade, SBRT has become increasingly used to treat high-risk operable patients who may otherwise be offered a compromise operation such as wedge resection, as well as standard-risk operable patients who would be able to tolerate lobectomy. The aim of this review is to discuss the current available data comparing SBRT and surgery with an emphasis on the ongoing randomized JoLT-Ca Sublobar Resection (SR) Versus Stereotactic Ablative Radiotherapy (SABR) for Lung Cancer (Stablemates) and veterans affairs lung cancer surgery or stereotactic radiotherapy (VALOR) studies. Methods: A search for studies comparing SBRT to surgery in early-stage NSCLC was conducted on PubMed. An emphasis was made on selecting publications between 2020 to 2024 to include the most recent studies on the topic. Meta-analyses, systematic reviews, propensity matched studies, retrospective reviews and national database analyses were included. ClinicalTrials.gov was searched for information pertaining to current randomized trials. Key Content and Findings: The majority of current data supports surgery over SBRT based on overall survival (OS), however, a direct comparison between the two has been challenging. Definitions for locoregional control, requirements of biopsy proven malignancy, the extent of surgical resection and mediastinal lymphadenectomy, and primary end points vary by study. Previous randomized controlled trials have failed to accrue, though two ongoing randomized studies, Stablemates (NCT02468024) and VALOR (NCT02984761), are nearing accrual which will better inform clinicians which treatment may be preferable to which patients. Conclusions: The current evidence favors surgery over SBRT for early-stage NSCLC in terms of OS, especially for standard-risk operable patients. For high-risk operable patients, surgery should still be considered standard of care, however the evidence is less clear, since many studies show similar recurrence rates. Based on the current evidence, we recommend surgical resection with mediastinal lymph node dissection for all patients with early-stage NSCLC who are operable. For patients medically unfit to undergo surgery, SBRT should be considered the standard of care.