title: Comparative effectiveness of surgery and radiosurgery for stage I non-small cell lung cancer.
abstract: BACKGROUND
  Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), stereotactic body radiotherapy (SBRT) has been disseminated as an alternative therapy. The comparative mortalities and toxicities of these treatments for patients of different life expectancies are unknown.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify patients who were 67 years old or older and underwent SBRT or surgery for stage I NSCLC from 2007 to 2009. Matched patients were stratified into short life expectancies (<5 years) and long life expectancies (≥5 years). Mortality and complication rates were compared with Poisson regression.
  
  
  RESULTS
  Overall, 367 SBRT patients and 711 surgery patients were matched. Acute toxicity (0-1 month) was lower from SBRT versus surgery (7.9% vs 54.9%, P < .001). At 24 months after treatment, there was no difference (69.7% vs 73.9%, P = .31). The incidence rate ratio (IRR) for toxicity from SBRT versus surgery was 0.74 (95% confidence interval [CI], 0.64-0.87). Overall mortality was lower with SBRT versus surgery at 3 months (2.2% vs 6.1%, P = .005), but by 24 months, overall mortality was higher with SBRT (40.1% vs 22.3%, P < .001). For patients with short life expectancies, there was no difference in lung cancer mortality (IRR, 1.01; 95% CI, 0.40-2.56). However, for patients with long life expectancies, there was greater overall mortality (IRR, 1.49; 95% CI, 1.11-2.01) as well as a trend toward greater lung cancer mortality (IRR, 1.63; 95% CI, 0.95-2.79) with SBRT versus surgery.
  
  
  CONCLUSIONS
  SBRT was associated with lower immediate mortality and toxicity in comparison with surgery. However, for patients with long life expectancies, there appears to be a relative benefit from surgery versus SBRT.
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.|Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.|Yale Cancer Center, New Haven, Connecticut.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.|Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Pamela R
authors.initials: PR
authors.lastname: Soulos
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Laura D
authors.initials: LD
authors.lastname: Cramer
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.|Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.|Yale Cancer Center, New Haven, Connecticut.
authors.forename: Roy H
authors.initials: RH
authors.lastname: Decker
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.|Yale Cancer Center, New Haven, Connecticut.|Department of Thoracic Surgery, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Kim
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.|Yale Cancer Center, New Haven, Connecticut.|Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.|Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D057186:Comparative Effectiveness Research; D005260:Female; D006801:Humans; D015994:Incidence; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D006278:Medicare; D009367:Neoplasm Staging; D016017:Odds Ratio; D011013:Pneumonectomy / Q000009:adverse effects; D011832:Radiation Injuries / Q000453:epidemiology; D016634:Radiosurgery / Q000009:adverse effects; D018426:SEER Program; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Epidemiology; Medicare; Surveillance; and End Results (SEER); comparative effectiveness, non-small cell lung cancer, stereotactic body radiotherapy (SBRT), surgery
references.citation: JAMA Surg. 2014 Dec;149(12):1244-53
references.pmid: 25321323
references.citation: Int J Radiat Oncol Biol Phys. 2005 Nov 15;63(4):1010-5
references.pmid: 16115740
references.citation: Int J Radiat Oncol Biol Phys. 2008 Mar 1;70(3):685-92
references.pmid: 18164849
references.citation: Ann Thorac Surg. 1995 Sep;60(3):615-22; discussion 622-3
references.pmid: 7677489
references.citation: J Geriatr Oncol. 2013 Apr;4(2):157-65
references.pmid: 23795223
references.citation: JAMA. 2010 Mar 17;303(11):1070-6
references.pmid: 20233825
references.citation: J Thorac Cardiovasc Surg. 2010 Aug;140(2):377-86
references.pmid: 20400121
references.citation: Ann Surg. 2011 Aug;254(2):368-74
references.pmid: 21617585
references.citation: Clin Chest Med. 2002 Mar;23(1):103-21
references.pmid: 11901906
references.citation: J Thorac Cardiovasc Surg. 2013 Mar;145(3):692-9
references.pmid: 23174176
references.citation: Eur J Surg Oncol. 2012 Jun;38(6):516-22
references.pmid: 22244908
references.citation: J Surg Res. 2013 Jul;183(1):27-32
references.pmid: 23260233
references.citation: Int J Radiat Oncol Biol Phys. 2012 May 1;83(1):348-53
references.pmid: 22104360
references.citation: Med Care. 1998 Jan;36(1):8-27
references.pmid: 9431328
references.citation: Pract Radiat Oncol. 2013 Jan-Mar;3(1):e21-8
references.pmid: 24674269
references.citation: Ann Thorac Surg. 2012 Sep;94(3):895-901
references.pmid: 22835558
references.citation: J Geriatr Oncol. 2014 Apr;5(2):190-6
references.pmid: 24495701
references.citation: Radiother Oncol. 2008 Sep;88(3):359-67
references.pmid: 18768228
references.citation: J Geriatr Oncol. 2013 Oct;4(4):310-8
references.pmid: 24472473
references.citation: Ann Thorac Surg. 2009 Jun;87(6):1662-6; discussion 1667-8
references.pmid: 19463574
references.citation: Semin Oncol. 2014 Feb;41(1):40-56
references.pmid: 24565580
references.citation: Ann Thorac Surg. 2009 Nov;88(5):1566-72; discussion 1572-3
references.pmid: 19853114
references.citation: J Thorac Cardiovasc Surg. 2012 Jun;143(6):1314-23
references.pmid: 22341420